Child Psychology and Psychiatry

Paediatric neuropsychological assessment II: domains for assessment

Table 37.1 Memory assessment measures.

Assessment Target Reference Non-specific Age range Comments
function population abilities∗ (to nearest
(n) in each whole year)
age band

Automated Memory — short-term 59 — 67 4 — 22 Computer
Working Memory and working memory 59 — 100 4.7 — 16 administration
Assessment [26] Visual-spatial and 30 — 81 and scoring
verbal 110 — 117
18 — 48
Working Memory Memory — short-term
Test Battery for and working memory 100
Children [3] Visual-spatial and
verbal 74
100
Children’s Memory — verbal, 40 6 — 17
Auditory Verbal immediate and delayed
Learning recall and recognition
Test — 2 [27]

Wide Range Memory — verbal and 5 — 15
Assessment of visual, delayed and
Memory and immediate, recall and
Learning [28] recognition

Rey—Osterrieth Memory — visual, Planning, visuo- 6 — 15
motor skills
Complex Figure immediate, delayed
Sustained
[29,30] and recognition attention
(Matching to
Children’s Memory — visual, Sample subtest) 2 — 16 It is possible to
Memory verbal, immediate, predict a
Scale [31] delayed recall, 6 — 16 General Memory
attention, recognition, 5 — 14 Index Score
learning from WISC FS IQ

Digit Span Memory — auditory

(WISC-IVUK) [1] working

Rivermead Memory — everyday
Behavioural tasks
Memory Test
[32,33]

The Visual Memory — working and 4 — adult Computer
Memory stored, recognition and 3 — 16 administration
Battery [34] learning and scoring.
18—36 months Motor speed is
NEPSY — memory Memory — visual, 100 controlled

subtests [25] verbal, immediate and Appropriate
subtests: names
delayed and faces;
narrative;
Color Object Declarative memory 94 — 139 sentences; list
per 6-month learning
Assessment Test age band
Only preschool
(COAT) [4] memory
assessment

∗Intact senses and motivation are assumed in all cases.

238

Assessment

Table 37.2 Language assessment measures.

Assessment Target Reference Non-specific Age range Comments
function population abilities∗ (to nearest
(n) in each whole year)
age band

Clinical Language — 151— 267 Auditory 5 — adult Test — retest
Evaluation of spoken attention reliability on
Language expressive and some subtests is
Fundamentals — receptive 100 Auditory low
3 [35] attention
Language — 3—6 Test—retest
Clinical spoken 120— 217 reliability on
Evaluation of expressive and some subtests is
Language receptive low
Fundamentals —
preschool [36] Language — 4 — adult TROG-E was
spoken receptive published in 2005
Test for the grammar 3 — 16 and is a
Reception 3—8 computerized
of Grammar version of same
(TROG) [37] test

British Picture Language — 183— 423 Visual 1997 stimuli are
Vocabulary spoken receptive discrimination less ambiguous
Scale [38] naming grammar than those in
previous editions

Renfrew Language — 58— 101 Short-term 6 — 13
Language spoken 29 — 53 (working)
Scales [39] comprehension, auditory
word finding, 100 memory
Token Test [40] expression,
narrative speech 3 — 16 Appropriate
NEPSY — subtests:
language Language — phonological
subtests [25] spoken receptive processing;
comprehension of speeded naming;
language repetition of
concepts non-words;
comprehension of
Language — instructions
expressive and
receptive,
cognitive
processes related
to language

∗Intact senses and motivation are assumed in all cases.

239

Paediatric neuropsychological assessment II: domains for assessment

Table 37.3 Attention assessment measures.

Assessment Target Reference Non-specific Age range Comments
function population abilities∗ (to nearest
(n) in each whole year)
age band

Continuous Attention — visual 40 Age-appropriate 6 — adult Gender-
Performance sustained 29 — 58 reading differentiated
Test [6] attention and norms
impulsivity 40 Basic numeracy is
Test of (behavioural 100 required for some 6 — 15
Everyday inhibition) subtests
Attention [13]
Attention — 4 — adult Computer
Cambridge auditory and visual 5 — -16 administration
Neuropsycho- sustained and and scoring.
logical Test selective Motor speed is
Automated attention, controlled
Battery [34] response inhibition
NEPSY — Appropriate
attention Attention — subtest: Auditory
subtests [25] sustained, Attention and
selective and Response Set
divided

Attention —
auditory —
selective and
sustained
(vigilance)

∗Intact senses and motivation are assumed in all cases.

[8] Eden GF, VanMeter JW, Rumsey JM et al. (1996) [14] Benton AL. (1994) Neuropsychological assessment.
Abnormal processing of visual motion in dyslexia Annual Review of Psychology 45, 1–23.
revealed by functional brain imaging. Nature 382,
66– 9. [15] Elliot C. (1983) British Ability Scales Manual II.
Windsor, UK: NFER-Nelson.
[9] Lezak MD, Howieson DB, Loring DW, Hannay HJ,
Fischer JS (2004) Neuropsychological Assessment. [16] Kaufman AS and Kaufman NL. (1983) Kaufman
Oxford Unitversity Press. Assessment Battery for Children. Circle Pines, MN:
American Guidance Service.
[10] Crawford JR, Anderson V, Rankin PM, MacDonald
J. (2010) An index-based short-form of the WISC- [17] Rey A. (1941) L’examen psychologique dans un cas
IV with accompanying analysis of the reliability and d’encephalopathie traumatique. Archives of Psy-
abnormality of difference. British Journal of Clinical chology 28, 286–340.
Psychology 49, 235–58.
[18] Osterrieth PA. (1944) Le test de copie d’une figure
[11] Snowling MJ, Adams JW, Bishop DV, Stothard complexe: contribution a` l’e´ tude de la percep-
SE et al. (2001) Educational attainments of school tion me´ moire. Archives of Psychology 30, 286–
leavers with a preschool history of speech-language 356.
impairments. International Journal of Language and
Communication Disorders 36, 173–83. [19] Beery KE. (1997) The Visual Motor Integration Test:
Administration, Scoring and Teaching Manual, 4th
[12] Wechsler D. (2005) Wechsler Individual Attainment edn. Cleveland, OH: Modern Curriculum Press.
Test. London: The Psychological Corporation.
[20] Kempton S, Vance A, Maruff P et al. (1999) Exec-
[13] Manly T, Robertson IH, Anderson V. (1999) Test utive function and attention deficit hyperactivity
of Everyday Attention for Children (TEACh). Bury disorder: stimulant medication and better executive
St Edmunds: Thames Valley Test Co.. function performance in children. Psychology and
Medicine 29, 527– 38.

240

Assessment

Table 37.4 Spatial/visual assessment measures.

Assessment Target Reference Non-specific Age range Comments
function population abilities∗ (to nearest
(n) in each whole year) Some debate
age band regarding the
graduation of
Developmental Visual discrim- 6 — 16 Impulsivity may 2 — 14 test item
interfere with difficulty
Test of Visual ination, motor performance in 6 — 15 Parts A and B
the motor skill 8 — 14 measure
Motor Integra- skill and subtest 2 — 13 different
functions
tion [19] visuo-motor 6 — 14
7 — 14 Appropriate
integration 6 — 15 subtests:
Design copy;
Trail Making A Visual search 10— 101 Knowledge of 6— 16† arrows; route
and B [41—43] and sequenc- 90— 189 number and 3 — 16 finding
ing/motor 200— 300 alphabet
output sequence
19 — 59
Mental Visual — 23 — 50 Conceptual
Rotation — rotation of ability to take
British Ability abstract another person’s
Scales [15] figures perspective

Gestalt Visual — Knowledge of
Closure — meaningful industrialized
Kaufman stimuli naming world objects
Assessment
Battery for
Children [16]

Face Visual/spatial
Recognition ability — face
Test [14] recognition

Judgement of Visual—spatial
Line Orienta- judgement
tion [44]

Rey — Visual/motor 18 — 48
Osterrieth planning
Complex
Figure Test
(copy
condition)
[17,18,29,30]

Right-left ori- Spatial 7 — 16
entation [45] discrimination 100

NEPSY — visual Motor and

spatial visual

subtests [25] perception;

line

discrimination

∗Intact senses and motivation are assumed in all cases.
†Some extrapolated norms.

241

Paediatric neuropsychological assessment II: domains for assessment

Table 37.5 Motor assessment measures.

Assessment Target Reference Age range Comments
function population (to nearest
(n) in each whole year)
age band

Finger Tapping Motor speed 20 6 — 14 Gender-differentiated
Test [46] norms. Boys are
5 — 15 significantly better at
Purdue Motor dexterity 23 — 40 this task
Pegboard Test (fine) 40 4 — adult
[47,48] Practice effects are
Motor speed and 20 6—14 (no notable
Cambridge Neu- reaction time 100 norms for
ropsychological 9 — 11) Computer
Test Automated Motor strength 3 — 16 administration and
Battery [34] scoring. Motor speed is
controlled
Grip
strength [46] Sex and hand
preference
NEPSY — Motor dexterity and differentiated norms
sensorimotor motor speed;
subtests [25] imitation of Appropriate subtests:
sequences; fingertip tapping;
graphomotor speed imitating hand
and accuracy positions, manual
motor sequences,
visuomotor precision

[21] Ozonoff S, Strayer DL, McMahon WM, Filloux [27] Talley JL. (1993) Children’s Auditory Verbal Learn-
F. (1994) Executive function abilities in autism ing Test – 2. Professional Manual. Lutz, FL: Psycho-
and Tourette syndrome: an information processing logical Assessment Resources.
approach. Journal of Child Psychology Psychiatry
35, 1015– 32. [28] Sheslow D and Adams A. (1990) Wide Range
Assessment of Memory and Learning (WRAML).
[22] Bryson G, Whelahan HA, Bell M. (2001) Mem- Wilmington, DE: Wide Range.
ory and executive function impairments in deficit
syndrome schizophrenia. Psychiatry Research 102, [29] Kolb B and Wishaw I. (1990) Fundamentals of
29– 37. Human Neuropsychology, 3rd edn. New York:
Freeman.
[23] Gioia GA, Isquith PK, Guy SC, Kenworthy L.
(1996) Behaviour Rating Inventory of Executive [30] Meyers JE and Meyers KR. (1995) Rey Complex
Function. Psychological Assessment Resources, Figure Test and Recognition Trial: Professional
Inc. Manual. Odessa, FL: Psychological Assessment
Resources Inc..
[24] Sherman EM and Brooks BL. (2010) Behaviour
Rating Inventory of Executive Function – [31] Cohen M. (1997) The Children’s Memory Scale. San
Preschool Version (BRIEF-P): test review and clin- Antonio, TX: The Psychological Corporation.
ical guidelines for use. Child Neuropsychology 16,
503– 19. [32] Aldrich FK and Wilson B. (1991) Rivermead
Behavioural Memory Test for Children: a prelimi-
[25] Korkman M, Kirk U, Kemp S. (2007) NEPSY - II: A nary evaluation. British Journal of Clinical Psychol-
Developmental Neuropsychological Assessment II. ogy 30, 161– 8.
San Antonio, TX: Psychological Corporation.
[33] Wilson BA, Forester S, Bryant T et al. (1991) Per-
[26] Alloway TP. (2007) Automated Working Memory formance of 11–14-year-olds on the Rivermead
Assessment (AWMA). Pearson Education. Behavioural Memory Test. Clinical Psychology
Forum 30, 8–10.

242

Assessment

Table 37.6 Executive function and social cognition assessment measures.

Assessment Target Reference Non-specific Age range Comments
function population abilities∗ (to nearest
(n) in each whole year)
age band

Delis — Kaplan Executive function Approx. 100 8 — adult Some parallel
Executive Function 22 — 32 7 — 15 versions of tasks.
System Executive 40 Good variety of
(D-KEFS) [49] function — predicts tasks
everyday function
Behavioural Computer
Assessment of Executive administration and
Dysexecutive function — working scoring. Motor
Syndrome memory and speed is controlled
(BADS) [50] planning
Sustained 4 — adult Computer
Cambridge attention administration and
Neuropsychological (matching to scoring. Motor
Test Automated sample speed is controlled
Battery [34] subtest)

Trail Making A and Executive 10 — 101 Number and 6—15 (some Parts A and B
B [41,42,43] function — motor 18 — 48 alphabet extrapolated measure
planning and 27 — 55 sequence norms) independent
Rey — Osterrieth disinhibition ability functions
Complex Figure Executive 6 — 15
Test (copy function — visual Visuo-motor
condition only) planning skills
[17,18,29,30]
Wisconsin Card Executive Colour vision, 6 — adult There is a positive
Sorting Test [51] function — cognitive basic relationship
flexibility; concept numeracy between years in
formation education and
performance
Stroop Word and Executive 14 — 29 Colour vision, Collated
Colour Test [52,53] function — inhibition literacy norms for All three conditions
of a prepotent 7 — 16 must be
response administered to
control for speed of
Diagnostic Analysis Social cognition — 25 — 305 Sustained 3 — adult processing
of Non-verbal receptive 100 auditory
Accuracy 2 [54] non-verbal ability; attention (collated Body language
voice and face norms)† subtest has been
NEPSY — attention recognition dropped for the
and executive 3 — 16 most recent edition
function Executive
subtests [25] function — inhibit Appropriate
automatic response, subtests: inhibition,
planning and clocks, animal
organization, shift sorting, design
set fluency, Statue

∗Intact senses and motivation are assumed in all cases.
†Child faces only.

243

Paediatric neuropsychological assessment II: domains for assessment

[34] The Cambridge Neuropsychological Test Automated [46] Finlayson MAJ and Reitan RM. (1976) Handedness
Battery (CANTAB). Cambridge, UK: CeNeS Phar- in relation to measures of motor and tactile function
maceuticals, 2001. in normal children. Perceptual and Motor Skills 43,
475– 81.
[35] Semel E, Wiig EH, Secord WA. (2006) Clinical
Evaluation of Language Fundamentals, 3rd UK edn. [47] Tiffin J. (1968) Purdue Pegboard: Examiner Manual.
London: The Psychological Corporation. Chicago, IL: Science Research Associates.

[36] Wiig EH, Secord W, Semel E. (2006) The Clinical [48] Gardner RA and Broman M. (1979) The Purdue
Evaluation of Language Fundamentals – Pre-school Pegboard: normative data on 1334 school children.
Version. San Antonio, TX: The Psychological Cor- Journal of Clinical and Child Psychology 8, 156– 62.
poration.
[49] Delis DC, Kaplan E, Kramer JH. (2001) The Delis-
[37] Bishop DVM. (2003) Test for the Reception of Kaplan Executive Function System (D-KEFS). San
Grammar. Manchester, UK: Chapel Press. Antonio, TX: Psychological Corporation.

[38] Dunn L, Dunn D. (2009) The British Picture Vocab- [50] Emslie H, Wilson F, Burden V, Nimmo-Smith I,
ulary Scale, 3rd edn. Windsor, UK: NFER-Nelson. Wilson B. (2003) Behavioural Assessment of Dysex-
ecutive Syndrome. Thames Valley Test Company.
[39] Renfrew C. (1995) The Renfrew Language Scales.
Oxford: Winslow. [51] Heaton RK, Chelune GJ, Talley JL, Kay GC,
Curtiss G. (1993) Wisconsin Card Sorting Test
[40] De Renzi E and Faglioni P. (1978) Development Manual – Revised and Expanded. Lutz, FL: Psy-
of a shortened version of the token test. Cortex 14, chological Assessment Resources.
41– 9.
[52] Golden JC. (1992) Stroop Word and Colour Test:
[41] Reitan RM. (1971) Trail making test results for A Manual for Clinical and Experimental Uses.
normal and brain-damaged children. Perceptual and Chicago: Stoelting.
Motor Skills 33, 575– 81.
[53] Comalli PE, Wapner S, Werner H. (1962) Inter-
[42] Spreen O and Gaddes WH. (1969) Developmental ference effects of the Stroop Colour Word Test
norms for 15 neuropsychological tests age 6 to 15. in childhood, adult and aging. Journal of Genetic
Cortex 5, 170– 91. Psychology 100, 63–5.

[43] Army Individual Test Battery. Trail Making B Man- [54] Nowicki S, Duke MP. (1994) Individual differences
ual of Directions and Scoring. Washington, DC: War in the non-verbal communication of affect. The
Department, Adjutant General’s Office, 1994. diagnostic analysis of a non-verbal accuracy scale.
Journal of Non-Verbal Behaviour 18, 9–35.
[44] Lindgren SD and Benton AL. (1980) Developmen-
tal patterns of visuospatial judgement. Journal of
Pediatric Psychology 5, 217– 25.

[45] Benton AL. (1959) Right-Left Discrimination and
Finger Localization. New York: Hoeber.

244

Assessment

38

Assessment of Child Psychiatric Disorders

Helen Bruce1 and Navina Evans2

1Emanuel Miller Centre, London, UK
2Coborn Centre for Adolescent Mental Health, Newham Centre for Mental Health, London, UK

INTRODUCTION: WHY DO A PSYCHIATRIC Given the pragmatics of time and availability, when
ASSESSMENT? is it important to apply the specific additional
skills utilized in psychiatric diagnoses? We would
What is the rationale for choosing to undertake suggest that psychiatric assessments be undertaken
a psychiatric assessment? Various answers to when the following questions are pertinent:
this question have been suggested. For instance, 1. Is there a coexisting significant medical problem
Harrington [1,2] argues that a psychiatric assess-
ment focuses on four key questions: where medical skills can contribute to under-
standing the illness process?
• is a psychiatric disorder present? 2. Is there a question of diagnosis – for example,
• what sort of disorder is it? whether the child’s symptoms meet the diag-
• what other problems are present? nostic criteria for a bipolar disorder?
• why does the patient have the presenting 3. Is there a likelihood that medication will be
required as part of the management/treatment
problem(s)? plan?
4. Is an admission to hospital for further assess-
Hoyos [3] takes a more developmental perspec- ment or treatment required?
tive and contrasts assessment in child psychiatry
with assessment of psychiatric disorders in adults, SETTING THE STAGE FOR ASSESSMENT
arguing that understanding child development
is critical when assessing children as normative The general principles of assessment outlined
behaviour changes with developmental age. apply to children of any age. However, it is partic-
Scott [4] argues that making a correct diagnosis ularly important to bear in mind that the range of
requires applying a body of knowledge based psychiatric disorders seen may differ according to
on extensive research. The American Academy the child’s age and developmental stage.
of Child and Adolescent Psychiatry (AACAP)
Practice Parameters and Guidelines [5] say that The assessment of a child and adolescent usually
the psychiatrist needs to prioritize symptoms and will take place over several meetings, using infor-
diagnoses so that a reasonable treatment plan can mation from several different sources. An initial
address multiple problems. assessment interview is a key time to begin the
therapeutic process of engagement with a family
As we illustrate below, all of these rationales and it is important to try to get it right. It is also
emphasize important aspects of the psychiatric a key part of any assessment of factors that may
diagnostic process. In a busy, multidisciplinary, pose a risk to the child’s safety or well-being.
generic child mental health service, an additional
question might be posed concerning which chil- Consideration should be given as to whom to
dren need to be assessed by a child psychiatrist. see. With a younger child, it is usually helpful to

Child Psychology and Psychiatry: Frameworks for practice, Second Edition. Edited by David Skuse, Helen Bruce,
Linda Dowdney and David Mrazek.
 2011 John Wiley & Sons, Ltd. Published 2011 by John Wiley & Sons, Ltd.

245

Assessment of child psychiatric disorders

meet with the whole family at the start of the Table 38.1 Observing the child. Adapted from
interview, but at some stage in the assessment of Bruce and Evans [6] and Bruce and Keene [7],
a younger child, the parent/s or guardian should with permission.
be seen without the child being present. Where it
is age appropriate, a younger child must also be Aspect Observations
given time to speak with the interviewers – either
by focusing some of the family interview on them, Behaviour Appearance and dress
or by meeting with the child alone. An adoles- Emotional responsiveness
cent will usually wish to be seen for some of the Talk Mannerisms and
assessment without their parents. The assessment stereotypies
interview unfolds in a number of stages that are Anxiety and Activity level
outlined below. mood Any risky behaviour
Interactions Form:
INTERVIEWING FAMILIES • coherence and speed
Intellectual • spontaneity
Family interviews should begin by making the functioning • spontaneity
family welcome and putting them at their ease. • prosody
Then, exploration around key issues follows: what • articulation
do the family see as the problem, and who has Content:
the problem? How are they trying to deal with • persistence
it at present? What have they already tried and • interruption of attention
what help have they already received? How does • child’s interests
it affect their lives? Fearful or anxious

One strategy the assessor may use is to ask Restless
the family to work together in the session on an Disturbed or aggressive
exercise, for example drawing up a family tree. Withdrawn or shy
This gives the assessor an insight into how family Sadness
members relate to each other and also into the pre- Parent— child interaction
senting problem. Are the parents sensitive to the Interaction with other
child’s communications? How do they respond? family members
What is the parent’s own relationship like? Is one Interaction with clinician
family member ignored? Interaction with the
environment — toys and
It is also important to ask who else is important play
to the child but is not present. This could be a A brief overview of the
separated parent, or a grandparent, for example. child’s current level of
How would the family describe this absent person, cognitive ability will be
and what would they say if they were in the room? needed
Does this differ greatly from
INTERVIEWING CHILDREN AND their chronological age?
ADOLESCENTS

With the younger child, it may not be possible
formally to examine the child’s mental state and
the clinician will need to rely on observation.
This should include an observation of the child’s
behaviour, interactions with family, interactions
with clinicians, and play. Key aspects of the child’s
functioning and behaviour to note are shown in
Table 38.1.

It is important to take into account develop-
mental issues and have a good understanding of

246

Assessment

the particular young person’s stage of emotional, They may not agree they have a problem at all.
cognitive and psychological development, which Even if they do not agree with the parent or
may differ according to their physical maturity. It referrer, the examiner can still establish a rapport,
is important that the child’s or adolescent’s individ- and it is important to engage with the young
ual autonomy is given due respect. This issue can person. As with younger children, the issue of
cause tension in the assessment phase, but should confidentiality and its limits should be established.
not be ignored. Confidentiality is linked with this The process of assessment should be explained
issue. It will be important that children can speak clearly. A psychiatric mental state examination
in confidence about certain issues. However, the should be carried out (see Box 38.1). The interview
limits to confidentiality with respect to concerns should also include a sexual, forensic, and drug
about the safety/well-being of themselves and oth- and alcohol history.
ers need to be outlined to them. Thus, it may not
always be possible to guarantee full confidentiality, It is important to end the interview in a way that
and the young person is entitled to a full expla- leaves children and adolescents feeling that their
nation of how this right will, as far as possible, perspective matters. Other useful information can
be respected. Many of those young people whose also be gained at this stage. It is important to ask
difficulties persist into adulthood will have their the young person if there is anything else they
first encounter with mental health services dur- would like to talk about or that they think the
ing their childhood. The nature of this experience interviewer should know that would be helpful for
will affect their future compliance and engage- the assessment. It is also important to ask if they
ment with mental health services, so it is especially want to ask any questions about the assessment,
important to consider the long-term implications possible interventions, or any other matters of
of their interaction with professionals at this stage. concern or interest to them. With a younger child,
a helpful technique is to ask the child: ‘if you
When seeing an adolescent it is helpful to had three wishes what would you wish for?’ They
establish what they personally see as the problem. often respond giving useful information about their

Box 38.1 Mental State Examination (MSE)

An MSE should be conducted with every child and adolescent being assessed. It is informed by
the child’s history, the assessment of other relevant factors and the conditions under which the
assessment is taking place. It will also be informed by the developmental stage of the child/
adolescent.

The MSE is used as part of the wider formulation to plan the next steps in management.
It is an active process conducted as often as needed throughout any intervention with the
child/adolescent.

The domains covered in a MSE include:

• Appearance, attitude and behaviour

• Mood and affect

• Speech

• Thought processes and content

• Perception

• Cognition

• Insight and judgement

• Risk

Clinicians will need to draw on their communicative skills with children and adolescents in
order to conduct a successful MSE.

247

Assessment of child psychiatric disorders

situation, fears and worries, using terms and a be shared between family members. It is important
context that is meaningful to them. to be aware of not being drawn in to colluding with
any secrets between family members.
INTERVIEW WITH THE PARENT(S)
OR CARER PHYSICAL EXAMINATION
AND INVESTIGATIONS
It is important to obtain from the parent(s) a thor-
ough description, both of the current problem and Most children who attend child mental health ser-
an account of the child’s developmental, medical vices are not routinely examined medically. It is
and school history. The key points are summarized important that consideration is given to a physical
in Box 38.2 [6,7]. examination, if one has not already been done by
the GP or Community Paediatrician. Reasons for
The parents can be interviewed together with this assessment include the possibility of an under-
the young person or separately. Many young peo- lying undetected physical condition that has caused
ple want to know what is being said about them a child’s difficulties, or the prescription of medi-
and should not be excluded. At times it may be cation that could have physical side effects, such
more appropriate for the parents to be seen sep- as risperidone or methylphenidate. Guidelines can
arately, as when the young person is extremely be found that are relevant to each medication
agitated or unwell, or if the parents feel concerned and indicate the essential elements of physical
about talking in front of the young person. If this examination – for example, the European Clini-
is done, the young person should be informed that cal Guidelines for Hyperkinetic Disorder [8] – but
the discussion is taking place and it should be made most National Health Service Trusts also have their
clear to all involved what level of information will

Box 38.2 Information to be obtained from the parent(s)

• Current problem as parent/s sees it and its effect on the family
• Behavioural problems (e.g. aggression, conduct problems, truancy, running away)
• Any risky behaviour
• Emotional symptoms (anxiety, fears, depression, suicidality)
• Attention and concentration
• Activity levels
• School history, performance and attendance
• Family life and relationships, including any family history of illness
• Peer and sibling relationships
• Any recent adversity (e.g. bereavement, trauma)
• Developmental history
• Physical health
• The child’s temperamental characteristics
• The child’s strengths
• What the parents see as the child’s difficulties
• What help/interventions have already been tried
• What has previously been successful.

Adapted from Bruce and Evans [6] and Bruce and Keene [7], with permission.

248

Assessment

own prescribing guidelines that state minimum lev- or presenting difficulty is abnormal in relation to
els of physical investigations required in their poli- his or her age, gender, developmental stage and
cies. The AACAP Parameters [5] also recommend cultural background. The symptom needs to be
physical examination or referral to a practitioner persistent, severe and frequent and of a sufficient
who can undertake this. A baseline height and extent in order to be considered abnormal.
weight should always be recorded. Where there is
suspicion of an underlying medical condition, a full It will also be important to know if the symptom
physical examination is essential. A full neurolog- is leading to functional impairment in the everyday
ical examination may also be required if there is life of the child. Four main criteria can be used to
history indicative of a neurological disorder such as assess impairment:
developmental delay, epileptic fits or loss of skills. 1. interference with a child’s development;
Other indicators include a history or physiognomy 2. social restriction;
that suggests the child could have a congenital syn- 3. suffering or distress to the child;
drome. Useful pointers to congenital syndromes 4. effect on others.
include learning difficulty, dysmorphic features
(including unusual facial features) and extreme Different aspects of the child’s problems can be
values for height, weight or head circumference [1]. considered using a multiaxial framework, as has
previously been done in the ICD-10 International
Most children will not require further medical Classification of Mental and Behavioural Disorders
investigations unless there is a clinical indication in Children and Adolescents (ICD-10). However,
or abnormalities have been found on the physical revisions to our current classification systems in
examination. However, it is important to carry both the UK and USA are underway, and we refer
out appropriate blood tests if medication is being the reader to Chapter 35.
considered.
An adequate formulation of the child’s difficul-
OTHER SOURCES OF INFORMATION ties will require the clinician to piece together the
presenting features of the problem, with any aetio-
Other agencies, such as education or social logical factors, and to comment on the differential
services, which are involved with the family diagnosis, management and prognosis. This evalu-
or child, may have useful information to help ation will form the basis on which any intervention
understand the child’s problems. Schools can is planned.
provide particularly valuable accounts of a
child’s difficulties. It is usually best to obtain Attention must be paid to risk assessment and
structured reports, in the form of a set of specific associated management, especially with adoles-
enquiries. Potential informants include the child’s cents. Risks can include risk to self, risk to oth-
class teacher and any schools special education ers (within or outside of the family) or risk of
needs advisors. Depending on the nature of the abuse/neglect. The psychiatrist plays a crucial role
child’s problem, the enquiry can be supported by in risk management, and should attempt to manage
standardized questionnaires that are available for anxiety within the young person’s social network.
teachers such as the Conners’ Rating Scales for
Hyperactivity/Inattention. A school or nursery Formulation also requires the assessor to have
observation by the clinician (if resources allow) a good understanding of strengths, resilience and
will also yield valuable information. It is important protective factors. These can be exploited in the
to ensure that parental consent has been obtained management plan and enhance outcome.
if the clinician wishes to seek information from
such other sources. ACKNOWLEDGEMENTS

PUTTING IT ALL TOGETHER: We acknowledge with thanks Quay Books, Mark
CONSTRUCTING A FORMULATION Allen Healthcare Ltd, for giving permission to use
Table 38.1 and Box 38.2 as updated and adapted
First of all, the clinician will need to consider versions from Bruce and Keene [7].
whether the child’s behaviour, emotional state
REFERENCES

[1] Harrington R. (2005) Assessment of psychiatric dis-
orders in children. Psychiatry 4, 19–22.

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Assessment of child psychiatric disorders

[2] Harrington R. (2004) Assessment of child and ado- [6] Bruce H and Evans N. (2008) Assessment of child
lescent psychiatric disorders. Medicine 32, 11–13. psychiatric disorders. Psychiatry 7, 242–5.

[3] Hoyos C. (2008) Assessment of child psychiatric dis- [7] Bruce H and Keene B. (2010) Child mental health.
orders. Medicine 36, 475–7. In: Ali A, Hall I, Dicker A (eds), Essential Psychiatry
in General Practice. Quay Books, pp. 127–37.
[4] Scott S. (2002) Classification of psychiatric disorders
in childhood and adolescence: building castles in the [8] Taylor E, Do¨ pfner M, Sergeant J et al. (2004)
sand? Advances in Psychiatric Treatment 8, 205– 13 European Clinical Guidelines for Hyperkinetic Dis-
order. European Child and Adolescent Psychiatry
[5] American Academy of Child and Adolescent 13(Suppl. 1), 17– 30.
Psychiatry. (1997) Practice Parameters and Guide-
lines. Journal of the American Academy of Child and
Adolescent Psychiatry 36(10; Suppl.).

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39

Psychological Assessment

Michael Berger

Department of Psychology, Royal Holloway, University of London, Egham, UK

Psychological problems in children and young clinical practice: what the clinician learns through
people commonly result from the interplay of a their investigations profoundly influences what
complex of factors over time. The same problem happens by way of further action. Where the pri-
shown by different individuals can arise for any of a mary focus is on psychological functioning, a major
variety of reasons, and the same instigator can lead feature differentiating forms of clinical practice is
to individuals showing different problems. Aggres- the clinician’s theoretical orientation or ‘model’.
sion at home may occur because one individual is Models influence how the practitioner approaches
socially isolated, another is not coping with the assessment, how the problems are understood, the
learning demands of school, or in a third, because nature of the eventual formulations they offer, the
of family tensions. One child bullied at school may interventions undertaken and even the structure
become withdrawn and uncommunicative whereas of services [1]. This chapter describes an approach
another may be aggressive at home and disruptive to the psychological assessment of children, young
in school. Complexity is increased because the fac- people (hereafter children), their families and
tors that give rise to difficulties may not always others involved in their care based on a model
be the same as those maintaining them. Rejection derived from several sources.
by peers can lead to a loss of self-esteem, and
even if subsequently reaccepted, the individual MODELS
may remain hypersensitive to signs of rejection.
Models in health care commonly reflect the char-
Assessment (or ‘evaluation’, ‘diagnosis’, or acteristics of medical diagnostic systems for iden-
‘case conceptualization’) is the process whereby tifying disorders. In simplified form, these view
clinicians gather and interpret information from a a psychiatric disorder as something in the person
variety of sources to help understand and manage caused by a (usually) diagnosable disease or injury,
such problems. The information is elicited and requiring individual treatment by professionals to
collected using formal (structured) or informal restore a healthy state. The appropriateness of
observations and interviews, and special tests. such models for understanding psychological prob-
An ‘assessment’, ‘evaluation’ or similar refers lems is questioned, reflecting disagreements with
to a set of statements conveying the clinician’s both the specifics of diagnostic systems – such as
understanding of the nature of the problems and categorical conceptualizations [2] – and the associ-
the actions needed to manage them. This product ated approaches to psychological problems [1]. A
of the assessment process, referred to here as ‘social’ model, also simplified, views dysfunction
a ‘formulation’, is essentially an explanation or and disability as social constructs, not individ-
hypothesis about the nature of the problems and ual attributes, requiring social change to remove
what is required to manage or resolve them. the disabling consequences, ignoring the contribu-
tion of biological and psychological factors. From
Assessment requires specialist knowledge and
skills and is arguably the most critical part of

Child Psychology and Psychiatry: Frameworks for practice, Second Edition. Edited by David Skuse, Helen Bruce,
Linda Dowdney and David Mrazek.
 2011 John Wiley & Sons, Ltd. Published 2011 by John Wiley & Sons, Ltd.

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Psychological assessment

a psychological perspective, a model incorporat- in certain developmental (sensitive) phases for
ing biological, psychological and social parameters emerging patterns to function effectively [5]. Post-
and their impacts on functioning – a biopsychoso- natal development is recognized as non-linear,
cial model – has greater ‘real-world’ meaningful- involving major qualitative and quantitative
ness [3]. transitions from birth onwards. Underlying devel-
opment are differential changes in neural systems
A BIOPSYCHOSOCIAL MODEL functioning in typical environments. Some systems
only become fully functional well into adolescence
A biopsychosocial model recognizes the interplay or beyond [6]. Such requirements for an accept-
of multiple factors in the origins, maintenance and able model are encompassed in Bronfenbrenner’s
impacts of psychological problems on personal developmental bioecological theory [7].
functioning. As an alternative starting point,
it is complemented by adopting experimental In a bioecological-inspired ‘model’ (see
psychology and psychopathology as the primary Figure 39.1), the individual is at the centre of
knowledge bases. For child psychologists, sys- interacting nested systems extending from care at
temic, developmental, individual difference and home to the broader sociocultural and physical
sociocultural considerations are also basic to their milieu. These influence and can be influenced by
approach. This recognizes that biological systems the developing individual, ‘the biopsychosocial
develop and function in ongoing transactions person’ at the centre of the microsystem (Ref. [7],
between genetic endowment and experiences, p. xvi), and by each other. Bronfenbrenner’s [8]
within and across all levels of the developing ideas have had a profound effect on thinking
organism and environment, from cellular biochem- in developmental psychology, manifest in varied
istry to the physical and psychosocial worlds. These applications of bioecological theory. Figure 39.1 is
influences operate from conception (and before), an instance applied both to understanding clinical
over the lifespan [4], and may need to occur problems and to assessment. In this model, the
individual is at the centre of increasingly broader

Physical world Intra-individual systems
State
Self
Wider community IQ Motor skills
School & peer group Executive functions
Temperament
Family Language Memory

Intra-individual Social functions

Development

Figure 39.1 Schematic model of the main systems conceptualized as the major components of a
biopsychosocial model.
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Assessment

ecologies. The dashed circles symbolize ‘gated’ points to potential resources for intervention.
bidirectional transactions among and across all the The proposed model thus emphasizes the need to
main systems. That is, systems are not necessarily adopt a multilevel perspective in assessment while
open to all influences: for example, some indi- leaving the clinician free to decide when, where
viduals are more resilient than others; auditory and what to explore in more detail.
signals inaudible to people influence animals.
Within-system transactions occur and impact Nevertheless, all practitioners, irrespective of
on other systems. When parents collaborate, approach, must be familiar with and take account
rather than argue about the management of their of psychiatric and other relevant medical diagnoses
child, this can help the child to feel more secure and treatments, partly for ethical reasons, partly
and confident at home, supporting the parents’ for risk management, and because the functional
engagement. It also leads to the child being more impacts found in individuals with such diagnoses
likely to respond positively to their teachers and commonly need to be managed. For example,
other adults outside the home. an individual with attention deficit hyperactivity
disorder (ADHD) whose activity levels and
The intra-individual elaboration on the right concentration have benefited from medication
of Figure 39.1 illustrates some of the main gen- may still need psychological assessment and inter-
eral within-individual functional areas. These can ventions to manage the personal and other impacts
be differentiated if necessary, for instance, into on family life, education and peer relationships, of
finer-grain temperamental characteristics [9]. The growing up with ADHD characteristics.
model is superimposed on a developmental trajec-
tory symbolizing changes over time. The shading Ultimately, as with other models, it is the
indicates that factors operating pre-conception clinician who has to integrate the assessment
(such as radiation exposure), can influence physi- information into a coherent formulation with
cal status and functional development of children implications for intervention. Formulations are
conceived many years later. tentative explanations of the clinical phenomena.
They can change following feedback from clinical
A model such as this has several advantages encounters, from further investigations, and by the
for thinking about clinical problems and assess- ways in which the individual or family responds.
ment. It identifies potentially influential systems Depending on the assessment, the formulation may
interacting and giving rise to complexity in lead to one or more individualized interventions,
clinical phenomenology. It provides a structure ranging from focal to broad-based, implemented
for systematic assessment, reminding clinicians within any or several of the environments where
of the factors within the individual and the there are significant functional impacts. This
broader ecologies that need to be considered. approach again stems from recognizing that
Assessment also needs to take account of typical multiple differing influences may be involved
developmental changes, individual differences, in instigating and maintaining clinical problems.
and the ways in which characteristics are manifest Whether or not evidence-based interventions are
in cultural and ethnic variants. used will depend on the availability of suitable pro-
cedures, taking account of developmental status
Assessment is commonly structured using a and the circumstances of the child or young person.
mental or other aide memoir, identifying the
domains to investigate that are relevant to the Although there are differing views about the
identified problems. Within each, certain features contribution of psychological tests, when properly
may trigger more detailed probing, including used, tests can provide essential information to
the use of psychological tests. Other areas might aid clinical understanding and decision-making,
be ignored. Investigations can entail family and can be an important source of outcome-
meetings, home or school visits and the like, monitoring data.
where information from these contexts might be
useful. Importantly, the assessment process should PSYCHOLOGICAL TESTING
also identify the strengths within the individual
and the broader environments that protect and A psychological (psychometric) test is a system-
support daily functioning. Such information aids atic or rule-governed procedure for sampling
understanding of the presenting difficulties and psychological attributes and processes. These

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are not directly observable but are inferred health-care delivery. However, the model outlined
from behaviour that occurs naturally or that is here provides an adaptable and appropriate frame-
specifically provoked by the test procedure. For work for thinking about the often complex psycho-
instance, written responses to focused questions logical problems, circumstances and resources of
can tap attitudes to the ‘self’; special puzzle tasks children and young people, and for the clinical
require the use of spatial abilities. One of the assessment and management of such problems.
strengths of psychological tests is that questions
and tasks are clearly described in a test manual REFERENCES
with everyone asked to do the same thing under
similar conditions. Answers or performance on a [1] Kinderman P. (2005) A psychological model of
task are converted to a numerical score, which is mental disorder. Harvard Review of Psychiatry 13,
compared with the scores of a reference group. 206– 17.
This gives an indication of severity, for example
of depressed mood, the level of an ability (e.g. [2] Widiger TA. (2004) Classification and diagnosis:
above or below average spatial skills) or the Historical development and contemporary issues.
extent of functional difficulties such as social skills In: Maddux J and Winstead B (eds), Psychopathol-
difficulties. ogy: Foundations for a Contemporary Understand-
ing. Hillsdale, NJ: Lawrence Erlbaum, pp. 63–83.
Clinical tests take many forms, including
some that can be administered and scored by [3] Schneiderman N and Siegel SD. (2007) Mental and
a stand-alone computer or over the internet. A physical health influence each other. In: Lillienfeld
number produce computer-generated reports. All SO and O’Donohue WT (eds), The Great Ideas of
tests used clinically should meet accepted quality Clinical Science. New York: Routledge, pp. 329– 46.
standards [10], including applicability to the indi-
vidual to be tested. While tests are relatively easy [4] Gottlieb G. (2007) Probabilistic epigenesis. Devel-
to administer and score, clinical testing requires opmental Science 10, 1–11.
advanced knowledge and skills: an understanding
of measurement errors and their effects on score [5] Thomas MSC and Johnson MH. (2008) New
interpretation; judgement of the reliability of advances in understanding sensitive periods in brain
the results from the individual administration; development. Current Directions in Psychological
cross-checking (do the scores make sense?); and Science 17, 1–5.
incorporating the test results in a meaningful form
in the broader assessment. Criteria for ensuring [6] Burnett S, Bird G, Moll J et al. (2008) Develop-
the competence of test users are available [11]. ment during adolescence of the neural processing
of emotion. Journal of Cognitive Neuroscience 219,
Tests encompass the full range of clinical 1736– 50.
diagnoses in children and young people [12]
as well as abilities, attainments (achievement), [7] Lerner RM. (2004) Urie Bronfenbrenner: Career
temperament, social skills, self-image and other contributions of the consummate developmen-
psychological phenomena [13]. Tests of attention, tal scientist. In: Bronfenbrenner U (ed.), Making
memory and other special procedures, used for Human Beings Human: Bioecological Perspectives
instance in neuropsychological assessment, are on Human Development. Thousand Oaks, CA: Sage
considered in Chapter 37. Publications, pp. ix–xvi.

CONCLUDING COMMENTS [8] Bronfenbrenner U. (ed.). (2004) Making Human
Beings Human: Bioecological Perspectives on
This account does not cover the training and Human Development. Thousand Oaks, CA: Sage
experience necessary for the clinical psychologi- Publications.
cal assessment of children and young people, nor
the prioritization of objectives and other aspects [9] Rothbart MK. (2007) Temperament, development,
of the assessment process, including linking it to and personality. Current Directions in Psychological
intervention. Nor does it address applications in Science 16, 207– 12.
stepped and managed care or in other services
responsive to the economic and other constraints of [10] American Educational Research Association
(AREA). (1999) Standards for Educational and
254 Psychological Testing. Washington, DC: AREA.

[11] Berger M. (2009) A Standards-based Approach
to Training in Psychological Testing: A discussion
paper. Leicester: Division of Clinical Psychology,
British Psychological Society.

[12] Mash EJ and Barkley RA (eds). (2007) Assess-
ment of Childhood Disorders, 4th edn. New York:
Guilford Press.

[13] Murphy LL, Spies RA, Plake BS (eds). (2006) Tests
In Print VII. Lincoln, NE: University of Nebraska
Press.

Assessment

40

Family Therapy Assessment

Alexandra Mary John

Department of Psychology, University of Surrey, Guildford, UK

In this chapter I provide a brief overview of family a complex interplay of family relationships and
therapy assessment, outlining how theoretical ori- processes. For instance, a child’s school refusal
entations can influence assessment, the main goals could be regarded as serving a ‘positive’ function
for the assessment process, and the strengths and within the family if it facilitated communications
limitations of a family systems therapy approach between parents who were otherwise emotionally
to assessment. distant from each other. Equally, the presenting
difficulty may have arisen as a result of a family’s
WHAT IS FAMILY THERAPY? inability to adapt and adjust to changing fam-
ily circumstances – as, for instance, when a father
Family therapy, also referred to as couple and who previously worked away from home, now
family therapy, and family systems therapy, is works locally and begins to play a greater role in
an evidenced-based psychotherapy that seeks disciplining the children within the family, a role
to address a variety of emotional, behavioural previously undertaken by the children’s mother.
and other biopsychosocial difficulties through
working with family members who are in intimate Whatever the family conceives as the
relationships. Such relationships could include, ‘difficulty’ – that is, the reason they are seeking
for instance, married couples, children with their therapy – the family therapist will seek to reduce
parents, grandparents with their adult children any associated stigmatization and to work with
and grandchildren, and other kinship groups. the family towards a situation where there is some
Within modern family therapy, however, all family recognition that all family members have an impor-
members do not need to be directly involved tant part to play in facilitating an understanding
in therapy, though their roles and perspectives of the problem and in generating a solution.
can be discussed and considered by the family
members who are present Family therapy and family-based approaches
have been shown to be effective for a variety
From the perspective of the family therapist, the of clinical problems, such as anxiety, depression,
family milieu will have a significant bearing either psychosomatic problems and eating disorders [1].
on the development of a person’s presenting emo- More detail of family therapy interventions can be
tional and behavioural difficulty and/or on its main- found in the Chapter 44.
tenance. The individual’s ability to accommodate
and adjust to life experiences such as a change in TYPES OF FAMILY THERAPY AND THE
family configuration or a physical health difficulty, FOCUS OF ASSESSMENT
as well as the meaning ascribed to those experi-
ences, will be influenced by other family members. Over the last 10 years there has been a growth of
family therapy models, with each having different
Presenting difficulties are not, therefore, seen theoretical underpinnings, and a variety of psy-
to reside in individuals per se, but to result from chotherapeutic influences have become integrated

Child Psychology and Psychiatry: Frameworks for practice, Second Edition. Edited by David Skuse, Helen Bruce,
Linda Dowdney and David Mrazek.
 2011 John Wiley & Sons, Ltd. Published 2011 by John Wiley & Sons, Ltd.

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alongside structural, strategic communication and family members are relevant. Further, that the
narrative family approaches. For instance, we have various assessment processes will in some way
seen a shift from didactic approaches where ther- seek to enable therapists and families to consider
apists were experts in charge of changing family the relevance and importance of each family
relationships, to post-modern approaches such as member’s contribution to the situation with a view
Narrative Family Therapy, in which family mem- to identifying potential solutions to the family’s
bers are considered experts on family functioning concerns.
and where one goal of therapy is the recognition
and use of family strengths to facilitate change. GENERAL PRINCIPLES OF FAMILY
THERAPY ASSESSMENT
Inevitably, theoretical models will influence
to some extent where the focus of assessment Several principles guide the process of assessment
lies. For example, those working within a therapy in modern systemic approaches. First, that
model that emphasizes the importance of cognitive an explicit theoretical framework guides the
processes will encourage individuals to compare assessment process so that it will link coher-
their thought processes with a rational evaluation ently into subsequent interventions, providing
of evidence, and also to hear how other members ‘theory–practice’ links. Secondly, that the assess-
of the family, who each undertake their own ment process is designed to provide insights into
evaluations, view the matter. Thus the assessment important aspects of family functioning. Thirdly,
process will focus on ascertaining family member that assessment offers opportunities for gathering
cognitions and their evaluations of alternative baseline measures of problematic aspects of family
explanations for events. functioning against which future outcomes can be
measured [2].
In contrast, where presenting difficulties pertain
to family communication processes, emotional dif- GOALS OF FAMILY THERAPY ASSESSMENT
ficulties or life transition challenges, postmodern
approaches will view the problem as arising out of Family therapy assessment is guided by a funda-
‘oppressed’ stories that dominate an individual’s mental assumption that the observation of family
life and constrain the possibility of change. structure and processes as they unfold in the clin-
Assessment focuses on eliciting narratives from ical interview will reveal something of the nature
family members that illustrate their perspective of the presenting problem, its genesis and main-
on the matter of concern, and also the ways in tenance over time. Gaining an understanding of
which individuals see themselves in relation to these relationships can enable family therapists
each other and to the presenting difficulty. Once and the family to form intervention plans aimed
the dominant narrative has been identified (i.e. at addressing the relevant family relationships,
‘assessed’), then the way is open for a possible processes or narratives.
reauthoring (or rewriting) of the family story.
The question for the family therapist is how to
While the referral problem will influence the structure the assessment in such a way that impor-
type of systemic approach that therapists adopt, tant areas of family functioning are revealed. Var-
their choice of approach will also be influenced ious assessment frameworks have been proposed
by their personal values and the characteristics [3–6]. There are differences of focus and emphasis
of the services in which they work. For instance, between the various models and a variety of terms
some therapists working within a legal framework are used to capture different aspects of family func-
may need to bear in mind that this can militate tioning. Some major themes that emerge include:
against adopting certain postmodern therapeutic
practices – such as deliberately adopting a ‘con- • Gaining an understanding of the presenting
trary position’ – as legal frameworks have rigid problem: Families most frequently present to
rules acting as an external reality that needs to be clinical services with a ‘problem’, or ‘difficulty’,
taken into account. which is regarded as ‘belonging’ to one family
member. The family therapist will seek to gain
Despite the various theoretical frameworks an understanding of the complexities of the
within which assessment takes place, all family
system approaches share the recognition that
the perceptions, emotions and behaviours of all

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problem – for instance, its salience for all family neurology and genetic factors and how these
members, its meaning to them, their responses impact upon behaviour and emotions [8]. This
to it, and their views on aspects of the problems could lead the therapist to seek to ascertain, for
such as how and why it arose, and the effects it instance, if a child’s difficulties within the school
is having upon the family. system are related to genetically influenced
• Family structure, composition and organization: developmental factors. One question for the
Here, the therapist will try to elicit factors such family therapist when biopsychosocial factors
as who is in the family, the roles and responsi- are of particular relevance is how do they influ-
bilities adopted by various family members, and ence both individual and family functioning,
how the family organizes and regulates itself. For that is, what is the dynamic interrelationship
instance, do the parents form a dyadic subsystem between biological, psychological and family or
in which they are united in taking on the parent- social factors?
ing role, or is one parent more closely aligned • Relationship levels: The focus here is on the
with other family members? Over time, how do social relations within the family – what are the
families accommodate to internal and external subsystems within the larger family system, and
forces that impact upon them? For example, all how do these function in such a way as to account
families will need to adapt to developmental for variance between different families? These
child processes that lead the child from infancy subsystems may be formalized in some models
to adulthood. In response to these forces for of therapy into, for instance, tracking consis-
change, does the family reorganize itself in a tent patterns of behaviour that are displayed
way that is adaptive or in a way that proves or elicited between and from various combi-
maladaptive? Is the family organization stable nations of family members, ranging from the
enough for the family to respond to crises with- individual level (‘actor’ effects), to the family
out fragmentation? as a whole (the ‘group’ effect) [9]. To illustrate,
• Family processes: The therapist will want to elicit when examining the expression of affect within
the nature of reciprocal interactions and trans- the family, how warmth is consistently expressed
actions. That is, how family members respond to by a given family member constitutes an ‘actor’
each other and how interactions at one point in effect, while the way in which one individual
time have influenced, or potentially will influ- in the family elicits warmth from other fam-
ence, subsequent interactions between them. ily members would be regarded as a ‘partner’
Sequences of interactions will give rise to rela- effect [10].
tionship patterns that the therapist will be keen
to ascertain in so far as they are relevant to Within such frameworks, information will be
specific outcomes of interest. elicited from family members through a series
• Patterns of communication: Together, family of discussions between therapist and family. It is
members construct an understanding of given not easy, therefore, to make a sharp distinction
happenings. What are these co-constructed between assessment and intervention as these dis-
understandings, and how do they influence cussions may, in themselves, begin to have an
the ways in which families communicate impact upon family communication, organization
with each other? What is the affective tone and relationship patterns.
of interactions – how are families conveying
emotion and how are emotions influencing the THE PROCESS OF FAMILY THERAPY
communications between them? ASSESSMENT
• Biopsychological factors: These factors have
been seen to be important in, for instance, The therapist initially meets the family and
medical family therapy models where the rela- focuses upon gaining the perspectives of all family
tionship between medical health conditions and members through using both direct and circular
psychosocial dimensions is explored – as, for questioning. Circular questions enable the thera-
example, in diabetes, anorexia and asthma [7]. pist to take the feedback gained from one question
More recently, attention has been drawn and use it to shape the next and so allow for a joint
to emerging knowledge of brain chemistry, construction. The style of questioning aims to draw

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out similarities and differences in perspectives, CONCLUSIONS
and the strengths and limitations of family
members; through this process the family can gain Family systems therapy offers an approach to
a new way of understanding and experiencing assessment that sets an individualized present-
each other. ing ‘difficulty’ or ‘problem’ firmly within its wider
systemic context, offering opportunities for des-
Reflecting teams are usually a part of the infras- tigmatizing individuals, for enabling all family
tructure of this type of therapy. They usually members to feel heard and understood, to gain
consist of two or three clinicians who observe new insights and recognize new meanings. It offers
the therapeutic process, with the aim of offer- the potential for families to start the process of
ing opinions on both the process and content of constructing new and more helpful realities. Some
the therapy as it unfolds. They can contribute limitations of the approach have been noted. The
additional thoughts – for instance, with regard to majority of family therapy models use Western
observed or inferred family strengths and the white culture as their main frame of reference, and
meanings associated with behaviours within the the majority of therapists in the UK come from
family. Through this reflective process, more cre- this background. While the appreciation of differ-
ative and effective intervention strategies can be ent cultures, religions and family forms has been
generated. In addition, the reflecting team can acknowledged in recent years, there is a limited
ensure that the therapist’s own responses to the evidence base regarding the applicability of some
family, as well as any prejudices, are managed and systemic models to particular minority groups (e.g.
do not interfere with the therapeutic endeavour. single parent, gay, lesbian or blended families). An
open attitude regarding the legitimacy of a range of
When and how the reflecting team offers their values and attitudes across the diversity spectrum
observations is dependent on the school of family is essential if sensitive areas are to be explored in
therapy adopted. Some teams choose to sit behind a helpful and constructive way.
a one-way mirror, whilst others sit in the room
with the family. The team can choose to interrupt REFERENCES
the assessment or intervention if they consider
an area needs further exploration. Or they can [1] Carr A. (2009) The effectiveness of family ther-
take a prearranged break with the therapist to apy and systemic interventions for child problems.
consider information gained so far. Feedback from Journal of Family Therapy 31, 3–45.
the reflecting team can be fed back directly to the
therapist, with the therapist feeding back in turn [2] Cook WL. (2005) The SRM approach to family
to the family. Alternatively, the reflecting team assessment. An introduction and case example.
can discuss the assessment with each other in front European Journal of Psychological Assessment 21,
of both the therapist and family, who can in this 216– 25.
way share in their observations. These procedures
provide a collaborative way for families to generate [3] Stanton M. (2009) The systemic epistemology of
empowering solutions to their difficulties. the speciality of family psychology. In: Bray JH and
Stanton M (eds), The Wiley-Blackwell Handbook of
RESEARCH ASSESSMENT TOOLS Family Psychology. Wiley-Blackwell, pp. 5–20.

There are a variety of more formal direct and [4] Van Geert PLC and Lichtwarck-Aschoff A. (2005)
indirect assessment tools that can provide a picture A dynamic systems approach to family assessment.
of aspects of family functioning. These include, for European Journal of Psychological Assessment 21,
instance, the Family Environment Scale [11] and 240– 8.
the Circumplex model and Family Adaptability
and Cohesion Evaluation Scale (FACES) [12]. The [5] Pincus D. (2001) A framework and methodology
strengths and limitations of a wide variety of such for the study on nonlinear, self organising fam-
assessment tools with respect to their utility within ily dynamics. Nonlinear Dynamics, Psychology and
a child welfare context, and the ease with which Life Sciences 5, 139–73.
they link to therapeutic models of intervention,
can be found in Johnson et al. [13]. [6] Bray JH. (2009) Couple and family assessment. In:
Bray JH and Stanton M (eds) The Wiley-Blackwell
Handbook of Family Psychology. Wiley-Blackwell,
pp. 151– 164.

[7] Graca Pereira M and Smith TE. (2006) Evolution
of the biopsychosocial model in the practice of

258

Assessment

Family Therapy. International Journal of Clinical [11] Moos R and Moos B. (1986) Family Environment
and Health Psychology 6, 455–67. Scale Manual, 2nd edn. Palo Alto, CA: Consulting
[8] Sluzki CE. (2007) Interfaces: towards a new gen- Psychologists Press; San Francisco: Jossey-Bass,
eration of systemic models in family research and
practice. Family Process 46, 173– 84. [12] Olson D H. (1989) Circumplex Model of family
[9] Cook WL. (2007) The Round–Robin Family assess- systems: family assessment and intervention. In:
ment and Social Relations Model Analysis. In: Olson DH, Sprenkle DH, Russell CRS (eds), Cir-
Smith SR and Hander L (eds), The Clinical Assess- cumplex Model: Systemic Assessment and Treatment
ment of Children. Lawrence Erlbaum Associates, of Families. New York: Haworth Press, pp. 7–49.
pp. 99–114.
[10] Eichelsheim VI, Dekovic M, Buist KL et al. (2009) [13] Johnson MA, Stone S, Lou C, Ling J, Mizrahi
The Social Relations Model in family studies: a P, Austin MJ. (2006) Family Assessment in Child
systematic review. Journal of Marriage and Family Welfare Services: Instrument Comparisons. Report
71, 1052– 69. Prepared by the Centre for Social Services Research
(CSSR) at the University of Berkeley.

259

Section 7

Approaches to
Intervention

Approaches to intervention

41

Discovering Psychiatric
Pharmacogenomics

David A. Mrazek

Department of Psychiatry and Psychology, Mayo Clinic College of Medicine, Rochester, MN, USA

THE TREATMENT OF CHILDREN approved for use in the USA. The introduction
WITH PSYCHOTROPIC MEDICATIONS of fluoxetine a few years later had another major
impact on the treatment of OCD and again
The development of psychopharmacological children treated with fluoxetine who had been
interventions for the treatment of child psychiatric intractable to any form of psychotherapeutic
conditions dramatically changed the practice of treatment did respond to this new medication. Of
child psychiatry over the course of the twentieth course, not all children responded to clomipramine
century. At the beginning of the century, there or fluoxetine, but some children did show dramatic
was not yet a single medication identified that improvements in response to treatment with
could help children to deal with the symptoms these medications. This variability in response to
of child psychiatric illnesses. By 1937, it was specific medications remains one of the greatest
discovered that stimulants could help children challenges in using psychotropic medications.
with hyperkinetic behaviour [1]. Gradually, over The introduction of pharmacogenomic testing
the intervening years many other psychotropic has provided the first important tool that is now
medications have been demonstrated to have available to improve our ability to identify a safe
potential therapeutic benefits for children with a and effective medication for a specific patient.
wide range of psychiatric disorders and symptoms.
NATIONAL DIFFERENCES IN THE
The history of the treatment of children with PRESCRIPTION OF PSYCHOTROPIC
severe obsessive-compulsive disorder (OCD) MEDICATIONS FOR CHILDREN
provides insight into the clinical appreciation
of the power of new medications. Before the In both the USA and Britain, the benefit of the full
development of medications to treat the most range of psychotropic medications has been gradu-
extreme forms of OCD, there were many children ally appreciated. However, it is widely recognized
who were treatment resistant to psychotherapy that the use of psychotropic medication in the
and behavioural therapy. These included quite USA is far more extensive than in Britain. While
intelligent children who had been very intensively it is important to understand better the multiple
treated. Many of the families of these children reasons that psychopharmacological treatment is
had nearly given up hope until reports of positive more widespread in the USA, one reason for this
clinical trials in adult patients were published. difference is that with more experience of pre-
Clomipramine became available in Canada before scribing psychotropic medication clinicians have
it was approved for use in the USA. During personally observed the clinical benefit for some
this time, US families would make regular trips children. Given this observation, many clinicians
to Canada, until clomipramine was eventually

Child Psychology and Psychiatry: Frameworks for practice, Second Edition. Edited by David Skuse, Helen Bruce,
Linda Dowdney and David Mrazek.
 2011 John Wiley & Sons, Ltd. Published 2011 by John Wiley & Sons, Ltd.

261

Discovering psychiatric pharmacogenomics

have focused on this potential for positive outcome Schoolchildren in the USA and Britain learn
even in the light of relatively low certainty that any that both the Rosetta stone and the genetic code
given child will benefit. Essentially, the potential are important examples of famous breakthroughs
reward of a dramatic response has been judged in our understanding of the world. The Rosetta
a sufficiently valuable benefit to justify treatment stone represents an ability to use a familiar
even knowing that as many as half of the treated language to translate a cryptic form of writing of
patients will not have an effective response. the past. Breaking the genetic code allowed us to
translate the language of nucleotides in a way that
Currently, psychotropic medications play a provides an understanding of the nature of individ-
role in the treatment of children with virtually ual genetic variability. What has been amazingly
every psychiatric diagnosis. Yet, the evidence slow to be realized is that variations in the genetic
base for the implementation of psychopharma- sequences of our patients give us the ability to pre-
cological treatment remains relatively subjective. dict their responses to psychotropic medications.
Furthermore, inconsistencies in the conduct and
reporting of clinical trials have led to considerable As outlined in the previous section, we have
controversy. At the heart of this dialogue is the successfully developed medications to treat
clinical observation that many children respond the symptoms of child psychiatric disorders.
dramatically to psychotropic medications while In addition to the selective serotonin reuptake
other children do not respond at all or, in fact, get inhibitors (SSRIs) that are used for mood disorder
worse. Despite years of investigation, it has only and OCD, we also have stimulants and atomox-
been in the last decade that our understanding of etine for attention deficit disorder. The atypical
some of the biological factors responsible for these antipsychotics are used for schizophrenia and
variable responses has begun to come into focus. bipolar disorder, which is also treated with lithium
and other mood-regulating medications. While
There are two major issues that have slowed clinicians have learned that these medications
the adoption of psychopharmacological treatment can be extremely effective for some children, the
in both the USA and Britain. The first is the sobering reality is that they can also make other
recognition that there are a wide range of adverse children much worse. Until very recently, there
drug effects that occur in patients treated with any was no other alternative but to proceed with a
class of psychotropic medications. The second is ‘trial-and-error’ strategy to search for the right
an almost universal appreciation that there is wide medication for a particular child.
individual variability in the response of children
to treatment with psychotropic medications. After An appreciation of how predictions of medi-
years of using empirical approaches to guide cation response can be derived requires learning
the use of psychotropic medications for child about gene structure and function. The most
psychiatric illnesses, there is now an evidence- straightforward examples are genotyping drug
based methodology to aid clinicians both to select metabolizing genes, such as the cytochrome P450
medications and to predict the appropriate dosage 2D6 gene, that produce enzymes that metabolize
for a specific patient. psychotropic medications (Table 41.1).

WHAT IS PSYCHIATRIC Table 41.1 The 2D6 relative role in the
PHARMACOGENOMICS? metabolism of common antidepressants.

Psychiatric pharmacogenomics is a scientific Primarily Substantially Minimally
approach to using the measurement of genetic metabolized metabolized metabolized
variability to predict the medication response of a by 2D6 by 2D6 by 2D6
specific child. Pharmacogenomics is not an easy
discipline to approach for psychiatrists who are Desipramine Amitriptyline Citalopram
not familiar with molecular genetics, but it can be Doxepine Bupropion Desvenlafaxine
mastered by systematically working through the Fluoxetine Duloxetine Escitalopram
basics of how changes in gene structure influence Nortriptyline Imipramine Fluvoxamine
gene function [2]. Paroxetine Mirtazapine Sertraline
Venlafaxine Trazodone

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Approaches to intervention

THE CYTOCHROME P450 2D6 GENE acute overdose of fluoxetine. Pharmacogenomic
testing would have revealed that this child was at
The cytochrome P 450 2D6 gene (CYP2D6) has high risk for a fatal outcome if given high doses
been studied for the last 30 years and is only one of fluoxetine.
of dozens of genes that can provide insight into the
response of a patient to a medication [3]. However, Ultra-rapid 2D6 substrate metabolizers
the beginning of child psychiatric pharmacoge- Children who have three or more active copies of
nomics emerged from the study of variations in the 2D6 gene or who have two or more copies of the
drug metabolism of 2D6 substrate medications. upregulated alleles of CYP2D6 have been demon-
For child psychiatrists, the testing of CYP2D6 strated to metabolize 2D6 substrates very quickly.
allows them to determine with a high degree of These children are usually unable to achieve ther-
certainty whether a particular child will be able apeutic serum levels of 2D6 substrate medications
to tolerate a medication like paroxetine, fluoxe- at traditional doses. The demonstration of this
tine, atomoxetine, risperidone or haloperidol as a very rapid metabolism has been documented by
consequence of their ability to metabolize these pharmacokinetic studies that have revealed signif-
medications. icantly decreased drug exposure in patients with
ultra-rapid metabolism [6].
The CYP2D6 gene is located on the smallest
autosome, which is chromosome 22. Its chromo- Child psychiatrists must also become aware of
somal address is 22q, which indicates that it is the implications of the CYP2D6 metabolic capacity
on the long arm of this short chromosome. It is of the mothers of breastfed infants, as the mental
composed of 1491 nucleotides and has nine exons status of these infants can be dramatically affected
that code for an enzyme with 497 amino acids. It if these mothers take prodrugs like codeine. A
is one of the most highly variable genes that are breastfeeding mother who is an ultra-rapid meta-
commonly genotyped. The more than 100 variants bolizer of 2D6 substrate medications will rapidly
are catalogued on the Karolinska Institute web- metabolize codeine to morphine. Given that high
site (http://www.cypalleles.ki.se/). Essentially, it is serum levels of morphine in the mother will result
possible to identify children who are either slow in high levels of morphine in her breast milk,
metabolizers or fast metabolizers. her infant will become increasingly lethargic as a
consequence of nursing. A tragic case of an infant
Poor 2D6 substrate metabolizers who died as a consequence of morphine toxicity
Children who lack even one ‘good’ copy of the was reported in the Lancet and has fortunately
CYP2D6 gene are classified as poor metaboliz- led to much greater awareness of the value of
ers. These children cannot make enough 2D6 pharmacogenomic testing in pregnant women [7].
enzyme to metabolize standard doses of fluoxe-
tine or paroxetine. Approximately 10% of patients BEYOND CYP2D6
of European ancestry are poor metabolizers and
experience moderate to severe side effects at stan- Given that there are many gene variations that
dard doses of these drugs. Both children and adults affect both drug metabolism and response, psy-
who are poor metabolizers of 2D6 have had fatal chiatric pharmacogenomic testing is increasingly
toxic reactions to 2D6 substrate medications [4,5]. assessing variation in many relevant genes that
ultimately influence how a particular patient will
The case of a 9-year-old boy who was treated respond to a specific medication. It is increasingly
with up to 100 mg of fluoxetine for the treatment of apparent that clinicians will need to systematically
OCD with comorbid Tourette’s disorder has been review the implications of these gene variations for
described [4]. The boy developed status epilep- the medications that they prescribe [2].
ticus and then died of a cardiac arrest. It was
subsequently determined that he had two inac- Currently, it is possible to order the geno-
tive copies of the CYP2D6 gene. At autopsy, typing of both drug-metabolizing enzyme genes
it was determined that his serum fluoxetine and and key target genes such as the serotonin
serum norfluoxetine levels were both in the toxic transporter (SLC6A4) and the serotonin receptor
range. This provided evidence that the elevated genes (HTR2A, HTR2C) to guide the selection
serum fluoxetine level was not the result of an and dosing of psychotropic medications. Other

263

Discovering psychiatric pharmacogenomics

informative genes include the catecholamine- genes will become increasingly commonplace in
O-methyltransferase gene (COMT) and the the USA. As the number of adverse effects of
dopamine receptor genes (DRD2, DRD3, DRD4). psychotropic medications decreases, the use of
these medications will, in all likelihood, increase
It is clearly most practical for clinicians to order even in children with less severe psychiatric ill-
these pharmacogenomic panels from laboratories nesses. Ultimately, the societal cost of mental
that provide comprehensive guidance on the impli- illness will drop as the chronic disabilities that
cations of these gene variations for specific psycho- we currently manage become more of a historical
tropic medications. Fortunately, there are now memory than our daily responsibility.
multiple reference laboratories that are providing
pharmacogenomic testing and interpretations. REFERENCES

FUTURE EXPECTATIONS FOR [1] Bradley C. (1937) The behavior of children receiving
PHARMACOGENOMICS TESTING benzedrine. American Journal of Psychiatry 94,
577– 85.
Many child psychiatrists in the USA have begun
to adopt clinical pharmacogenomic testing [8]. [2] Mrazek DA. (2010) Psychiatric Pharmacogenomics.
However, pharmacogenomic testing is still largely New York: Oxford University Press.
undiscovered in Britain. This is almost certainly the
direct result of the much wider use of psychotropic [3] Kirchheiner J, Nickchen K, Bauer M et al. (2004)
medications in the USA. However, it is safe to pre- Pharmacogenetics of antidepressants and antipsy-
dict that within the next decade there will be rapid chotics: the contribution of allelic variations to the
adoption of psychiatric pharmacogenomic testing phenotype of drug response. Molecular Psychiatry
on both sides of the Atlantic. The most important 9, 442– 73.
reason is that gene sequencing will become avail-
able as a standard component of a comprehensive [4] Sallee FR, DeVane CL, Ferrell RE. (2000)
clinical diagnostic evaluation. Today, in order for Fluoxetine-related death in a child with cytochrome
child psychiatrists to order a panel of informative P-450 2D6 genetic deficiency. Journal of Child and
pharmacogenomic genes, they must have a cogni- Adolescent Psychopharmacology 10, 27–34.
tive understanding of the rationale for the potential
benefit of testing. Of course, there is also a consid- [5] Koski A, Ojanpera I, Sistonen J et al. (2007) A
eration about whether the benefit is worth the cost fatal doxepin poisoning associated with a defective
of the testing. When the cost of genotyping the CYP2D6 genotype. American Journal of Forensic
entire genomic sequence of a patient falls below Medicine and Pathology 28, 259– 61.
US$1000, sequencing will become a standard com-
ponent of a comprehensive patient evaluation. The [6] Dalen P, Dahl ML, Ruiz ML et al. (1998) 10-
current director of the National Institute of Health Hydroxylation of nortriptyline in white persons with
in the USA has predicted that patients will be 0, 1, 2, 3, and 13 functional CYP2D6 genes. Clinical
routinely sequenced when the cost of sequencing Pharmacology and Therapeutics 63, 444– 52.
reaches $1000. Furthermore, he estimates that this
price point will be reached by 2015 [9]. After 2015, [7] Koren G, Cairns J, Chitayat D et al. (2006) Phar-
it will still be necessary to develop software to macogenetics of morphine poisoning in a breastfed
interpret the implications of the genetic variabil- neonate of a codeine-prescribed mother. Lancet
ity of our patients, but there will be a stampede of 368, 704.
bioinformaticists who will be competing to develop
the most effective methodologies to diagnose and [8] Wall CA, Oldenkamp C, Swintak C. (2010) Safety
treat both the traditional physical illnesses as well and efficacy pharmacogenomics in pediatric psy-
as what we currently refer to as mental illnesses. chopharmacology. Primary Psychiatry 17, 53– 8.

It is likely that in the next five years the genotyp- [9] Collins FS. (2010) The Language of Life: DNA and
ing of panels of pharmacogenomically informative the Revolution in Personalized Medicine. New York:
Harper.

INTERNET RESOURCE

Karolinska Institute, Human Cytochrome P450 (CYP)
Allele Nomenclature Committee: http://www.cypalle
les.ki.se/.

264

Approaches to intervention

42

Cognitive–Behavioural Therapy
for Children and Adolescents

Cathy Creswell1 and Thomas G. O’Connor2

1School of Psychology and Clinical Language Sciences, University of Reading, Reading, UK
2Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA

Cognitive–behavioural therapy (CBT) is a model [5], was developed in the context of conduct
treatment approach based on the general notion disorder but has proved useful for other childhood
that a psychological disorder is caused or main- disorders, including depression and anxiety. The
tained by ‘dysfunctional’ thought patterns and model focuses on the following:
lack of positively reinforced adaptive behavioural
coping strategies. CBT is a class of treatment; all • the child’s attending to, encoding and interpret-
cognitive–behavioural treatments aim to identify ing social cues (e.g. why did that child step on
and reduce cognitive biases or distortions and my foot?);
build effective coping and problem-solving skills.
After decades of extensive research on CBT in • developing goals for one’s own behaviour (e.g.
adult populations [1], CBT is now being applied what do I want to do now?);
to child and adolescent populations with success.
• generating potential solutions and evaluating
BASIC PREMISES OF THE CBT APPROACH their effects (e.g. what would happen if I hit
AND ITS ADMINISTRATION back at him?).

According to the basic CBT model, disorder is Several CBT programmes have been devised
conceptualized as resulting, in part, from the and shown to be clinically effective. Although there
individual’s cognitive distortions (such as false is some tendency to tailor the CBT treatment for
attributions or expectations of the self or other) a particular disorder (see studies cited below), it
that undermine positive coping and problem- is possible to make several basic statements about
solving behaviour. There is now considerable how CBT is administered. In general, CBT inter-
evidence that cognitive distortions exist and may ventions seek to break the cascade of maladaptive
play a causal – or at least contributing – role thoughts and feelings that lie between the cogni-
in many childhood disorders, with much of tive distortion and the destructive behaviour. This
the work focusing on depressed, anxious and occurs in a logical, stepped manner usually lasting
conduct-problem youth [2–5] (Box 42.1). Several 8–16 sessions, typically on a 1 session/week sched-
clinical and developmental models have informed ule (Box 42.2). A first step is to collate detailed
and been informed by research into the processes information about the settings that lead the child
by which distorted cognitions are developed to feel, for example, anxious and unable to cope
and influence behavioural/emotional problems. with a particular situation. A second step is to
One example, the social information processing help the child/adolescent to identify and differ-
entiate thoughts, feelings and somatic reactions
linked with these situations Subsequently, there is a
focus on self-talk, or helping the child to recognize

Child Psychology and Psychiatry: Frameworks for practice, Second Edition. Edited by David Skuse, Helen Bruce,
Linda Dowdney and David Mrazek.
 2011 John Wiley & Sons, Ltd. Published 2011 by John Wiley & Sons, Ltd.

265

Cognitive–behavioural therapy for children and adolescents

Box 42.1 Examples of key cognitions associated with childhood

Characteristics of clinically anxious children [3]
• Vigilant to threat
• Interpret ambiguity as more threatening
• Come to faster conclusions about threat
• Underestimate personal coping ability
• Anticipate distress (often exaggerated) in the face of threat
Characteristics of clinically aggressive children [4]
• Attend to less social cues
• Direct attention towards hostile social cues
• Interpret stimuli in a hostile manner
• Generate fewer solutions to social problems
• Positively appraise aggressive responses
• Positively appraise own ability to perform aggressive response
Characteristics of clinically depressive children [5]
• Selectively attend to negative features of events
• Report negative attributions (i.e. internal, stable explanations for positive events and

external, unstable explanations for negative events)

Box 42.2 Core steps in cognitive place. Relaxation is often included to improve the
—behavioural therapy (CBT) for child’s coping strategies and expand his/her coping
childhood anxiety repertoire. Throughout treatment children are
helped to evaluate their newly developed coping
• Recognize feelings and physical skills in ‘real-life’ settings, and these are rewarded
reactions where appropriate. This can continue for several
sessions, as the child learns to test new strategies
• Identify associated thoughts (e.g. and, through trial and error, to find strategies that
interpretations, attributions and work and to diagnose why other strategies do
expectations) not. Homework throughout the treatment process
fosters understanding of why feelings of anxiety or
• Cognitive restructuring/coping self-talk depression develop and how they might be man-
• Progressive muscle relaxation aged effectively. In addition, emphasis is placed
• Imaginary/in vivo (graded) exposure on developing rapport with the child/adolescent
• Self-evaluation and reward throughout the treatment. CBT programmes
value rapport, but unlike some approaches, do
how certain kinds of self-talk can be destructive not construct the treatment as working through
(‘I’ll look silly’) and promoting positive self-talk the relationship with the therapist. Instead, the
(‘I have done this OK before’). Using these skills, CBT therapist guides the child/adolescent to
children are then supported to develop a hierarchy reshape attributions and expectations in order
of anxiety-producing situations, which they to change behaviour. Treatments including a
gradually face, with a clear reward structure in family component are increasingly common, and
typically this means an ancillary focus on the
parents’ behaviour, or a parent’s own anxiety

266

Approaches to intervention

and how that may influence the child via the children with elevated behavioural/emotional
child–parent relationship. These approaches build symptoms exhibit cognitive distortions does
on and address the finding that parental anxiety not mean that these cognitive processes are
has been found to be a significant predictor of causally linked with disorder; neither does it
treatment failure of individual treatment of the necessarily imply that altering these cognitions
child [6]; parents who model poor coping, parent will produce positive behavioural change. Indeed,
in an overprotective manner and communicate it is somewhat surprising that little is known about
expectations to the child that she/he cannot cope the developmental constraints around CBT-based
with effectively may undermine the child’s individ- treatments, and clinical research has not yet
ual treatment [7]. Particularly valuable in this area demonstrated that a child’s developmental stage
are studies now underway that seek to manipulate predicts treatment outcome. This may be because
the degree of family involvement in order to the predictors so far considered (e.g. age) are weak
better understand treatment mechanisms. It is not indicators of the cognitive and social processes
yet clear what additional benefits are conferred by that are required for successful CBT. However,
these treatment models, but findings from these the theory and implementation of CBT has not
studies should be closely monitored because they been especially developmentally informed. So,
may have a substantial impact on how CBT-related for example, the traditional CBT model is not
treatments for children may be optimized. explicit about why the approach might work
with a 12-year-old but not with a 5-year-old. If
DEVELOPMENTAL CONSIDERATIONS there is a general impression, it is that CBT is
an effective treatment for depression and anxiety
We now know that depressed, anxious or conduct- in children aged around 8 years, with both short-
and long-term gains. In any event, it is clear that
problem-related cognitions are evident at an CBT may be very effective. It is worth noting
that Kendall and Southam-Gerow found that
early age. In a study of 5-year-olds, Murray and individual CBT was highly effective in treating
children/adolescents with anxiety disorders, and
colleagues found that higher rates of negative that approximately 90% were diagnosis-free more
than 3 years after treatment ended [10].
cognitions, defined as ‘spontaneous’ expressions
RECENT ADVANCES IN CBT PROGRAMMES
of hopelessness or low self-worth during an exper- FOR CHILDREN AND ADOLESCENTS

imentally manipulated card game with a friend, Recent clinical research findings on CBT in
children and adolescents are noteworthy in several
were observed in children whose mothers were, or respects. One is the enlarged range of conditions
for which CBT has produced large, reliable and
had been, depressed [8]. Significantly, differences clinically meaningful findings. So, for example,
in addition to depression and anxiety [10,11],
between the children of depressed and non- there are now studies showing positive effects
for post-traumatic stress disorder [12,13] and
depressed mothers were apparent only when the obsessive-compulsive disorder [14]. However, it
remains the case that most of the CBT studies
children were losing. Evidence that cognitive dis- are efficacy studies, that is, the treatment has
been shown to work under relatively controlled
tortions do not operate in a trait-like manner, even conditions. As a result, concerns about the gener-
alizability of the study effects have been expressed.
in 5-year-olds, is an important clinical and devel- These are real and important, but they should not
be seen as reasons for not undertaking standard
opmental lesson. Other studies also suggest that treatment protocols. In any event, what is needed

cognitive biases or distorted ‘filters’ exist in young

children and may be learned from parent-child

interactions. A study of 2 – 6 1 -year-olds found
2
that insecurely attached children showed poorer

understanding of negative emotions compared

with securely attached children; in other words,

they had more difficulty explaining or making

sense of negative emotions [9]. Findings from these

and many other studies are valuable not only for

what they say about the phenomena, but also for

the practical lessons they yield for assessing young

children. Greater integration of these methods in

clinical settings is feasible and a valuable next step

for advancing clinical assessment and treatment

monitoring (Box 42.3). Demonstrating that young

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Cognitive–behavioural therapy for children and adolescents

Box 42.3 Sample responses to ambiguous scenarios

You have arranged to have a party at 4 pm and by 4.30 no one has arrived
Cognitive bias — What do you think is most likely to have happened?
• Anxious: ‘Nobody wants to come to the party’
• Aggressive: ‘Nobody wants to come to the party’
• Non-clinical controls: ‘They might be late because there is bad traffic’

Behaviour — What will you do about it?
• Anxious: ‘Nothing. Feel upset’
• Aggressive: ‘Get cross and when I see them at school I will tell them I don’t want to be

friends with them’
• Non-clinical controls: ‘Phone around and see where they are and when they will arrive’

You are playing inside and your dog starts barking and growling outside
Cognitive bias — What do you think is most likely to have happened?
• Anxious: ‘There is someone I don’t know trying to get into my house’
• Aggressive: ‘Someone is stealing my bike from outside’
• Non-clinical controls: ‘Another dog is walking past outside’

Behaviour — What will you do about it?
• Anxious: ‘Hide’
• Aggressive: ‘Find the thief and hit them’
• Non-clinical controls: ‘Look out of the window and tell my dog to be quiet’

Adapted from Barrett PM, Rapee PM, Dadds MR, Ryan SM. Family enhancement of cognitive style in anxious
and aggressive children. Journal of Abnormal Child Psychology 1996;24:187—203.

now are studies that carry out CBT-based interven- Adolescents with Depression Study (TADS [11])
tions for child populations in conventional clinical and the Child Anxiety Multisite (CAM [16]) study.
settings using samples that are representative of In the TADS study, follow-up to 36 weeks shows
clinic settings. Work of that kind is underway. In that treatment-group differences apparent in the
a recently completed study of 41 children with earlier phases of treatment diminished over time,
anxiety disorder treated within a primary care with the result that there was convergence among
setting, we found equivalent outcomes (61% free the CBT-only, medication-only (fluoxetine), and
of primary anxiety diagnosis post-treatment) to CBT plus medication conditions [11]. The rate of
those found in trials conducted in specialist child adolescents with suicidal ideation (none commit-
anxiety clinics [15]. These preliminary findings are ted suicide in the trial) was considerably higher
promising and encourage the application of these in the medication-only group (15%) than in the
protocols in non-specialist settings. combined (8%) or CBT only (6%) conditions; that
is naturally a major consideration when making
Another recent advance in work on CBT in treatment decisions. Perhaps even more impres-
children and adolescents is that it is increasingly sive are data showing that CBT can be effective
being set up against or in addition to medication. as a treatment strategy even where drug treat-
In fact, there are several large-scale trials com- ment was ineffective [17]. However, this study
paring CBT with drug and combined conditions. did not include a CBT-only arm, and so it is not
Probably the best known are the Treatment for

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Approaches to intervention

possible to know whether CBT alone would have that CBT can be used as a general tool and across
been successful following drug treatment failure. a variety of settings.
The CAM study, in contrast, compared outcomes
of children aged 7 to 14 years with a diagnosed CONCLUSION
anxiety disorder randomized to either 14 sessions
of CBT, sertraline, a combination of sertraline and Children’s cognitions about their social world
CBT, or a placebo drug [16]. Based on a clini- reflect developmental histories that shape
cian’s global impressions of improvement, 81% of behaviour. CBT is concerned with how these
children were reported as ‘much’ or ‘very much’ cognitive processes may be altered and, when
improved following the combination treatment, altered, if there are consequential reductions in
60% for CBT, and 55% for sertraline, all of which psychiatric symptoms and improvements in social
were superior to outcomes from placebo (24%). functioning. Results from many clinical trials have
Importantly there was not a greater frequency of shown that CBT reliably improves outcomes in
adverse events amongst the sertraline group; how- children; recent studies show that CBT should no
ever, there were significantly greater incidence of longer be considered only for more mild cases,
symptoms of insomnia, fatigue, sedation and rest- and that the list of targeted disorders appropriate
lessness amongst children who received sertraline for CBT is increasing. Additionally, CBT has been
in comparison to CBT. shown to be as effective as, perhaps better than,
and possibly a useful adjunct to, medication. These
These findings and those of other studies findings are important for instilling confidence
have shown that assumptions about CBT being in recommending treatment for ill and distressed
appropriate only for more mild cases is no longer children and their families. A next step is to
supported by the evidence. Indeed, although its develop increasingly efficient modes of delivery to
impact is even greater when coupled with medica- improve access to this effective form of treatment.
tion, CBT is an important stand-alone treatment
and, in terms of its effectiveness and side-effect REFERENCES
profile, it can be considered as a first-choice treat-
ment rather than an add-on to other approaches, [1] Elkin I, Gibbons RD, Shea MT et al. (1995) Initial
such as medication. The question now for mental severity and differential treatment outcome in the
health professionals is not whether CBT is a National Institute of Mental Health Treatment of
reasonable treatment option, but rather how to Depression Collaborative Research Program. Jour-
increase the availability of CBT to children and nal of Consulting and Clinical Psychology 63, 841–7.
families. Another recent advance in CBT work
concerns the mediators of treatment (why does [2] Muris P. (2010) Anxiety-related reasoning biases in
treatment work?) and the moderators of treatment children and adolescents. In: Hadwin JA and Field
(what predicts who will respond and who will AP (eds), Information Processing Biases and Anxi-
not?). Findings from this research are important ety: A Developmental Perspective. Wiley-Blackwell,
for improving our understanding of the treatment pp. 21– 46.
process and for better targeting those who are most
likely to benefit from treatment. There are sug- [3] Orobia de Castro B, Veerman JW, Koops W, Bosch
gestions but, to date, not much consistency across JD, Monshouwer HJ. (2002) Hostile attribution of
studies. This is likely to improve as research studies intent and aggressive behaviour: A meta-analysis.
move on from asking if treatment works and take Child Development 73, 916– 34.
on the next stage of research, namely questions
about why and for whom treatment works. [4] Abela JRZ, Brozina K, Haigh EP. (2002) An exam-
ination of the response styles theory of depression
Finally, CBT is incorporated in prevention in third- and seventh-grade children: A short-term
programmes in universal, indicated and selected longitudinal study. Journal of Abnormal Child Psy-
samples. A recent review of school-based pro- chology 30, 515– 27.
grammes [18] indicated that they were effective
for anxiety, with effect sizes ranging from small to [5] Crick N and Dodge KA. (1994) A review and refor-
large. That is significant because it demonstrates mulation of social information processing mecha-
nisms in children’s social adjustment. Psychological
Bulletin 115, 74– 101.

[6] Cobham VE, Dadds MR, Spence SH. (1998) The
role of parental anxiety in the treatment of child-
hood anxiety. Journal of Consulting and Clinical
Psychology 66, 893–905.

269

Cognitive–behavioural therapy for children and adolescents

[7] Murray L, Creswell C, Cooper PJ. (2009) The apy, sertraline, and their combination for children
development of anxiety disorders in childhood: and adolescents with obsessive-compulsive disor-
an integrative review. Psychological Medicine 39, der. Journal of the American Medical Association
1413– 23. 292, 1969– 76.
[15] Creswell C, Hentges F, Parkinson P, Sheffield P,
[8] Murray L, Woolgar M, Cooper P, Hipwell A. (2001) Willetts L, Cooper PJ. (2010) Feasibility of guided
Cognitive vulnerability to depression in 5-year-old cognitive behaviour therapy (CBT) self-help or
children of depressed mothers. Journal of Child childhood anxiety disorders in primary care. Mental
Psychology and Psychiatry 42, 891– 99. Health in Family Medicine 7, 49–57.
[16] Walkup JT, Albano AM, Piacentini J et al. (2008)
[9] Laible DJ and Thompson RA. (1998) Attachment Cognitive behavioral therapy, sertraline or a combi-
and emotional understanding in preschool children. nation in childhood anxiety. New England Journal
Developmental Psychology 34, 1038– 45. of Medicine 359, 2753– 66.
[17] Brent D, Emslie G, Clarke G et al. (2008) Switching
[10] Kendall PC and Southam-Gerow MA. (1996) Long- to another SSRI or to venlafaxine with or without
term follow-up of a cognitive behavioural therapy cognitive behavioral therapy for adolescents with
for anxiety-disordered youth. Journal of Consulting SSRI-resistant depression. Journal of the American
and Clinical Psychology 64, 724– 30. Medical Association 299, 901– 13.
[18] Neil AL and Christensen H. (2009) Efficacy and
[11] The TADS team. (2007) The treatment for adoles- effectiveness of school-based prevention and early
cents with depression study (TADS). Archives of intervention programs for anxiety. Clinical Psychol-
General Psychiatry 64, 1132– 44. ogy Review 29, 208–15.

[12] Cohen JA, Deblinger E, Mannarino AP, Steer RA. FURTHER READING
(2004) A multisite, randomized controlled trial for
children with sexual abuse-related PTSD symptoms. O’Connor TG and Creswell C. (2005) Cognitive
Journal of the American Academy of Child and behavioural therapy (CBT) in developmental perspec-
Adolescent Psychiatry 43, 393– 402. tive. In: Graham P (ed.), Cognitive-Behaviour Therapy
for Children and Families, 2nd edn. Cambridge: Cam-
[13] Smith P, Yule W, Perrin S, Trannah T, Dalgleish bridge University Press; pp. 25–47.
T, Clark D. (2007) Cognitive behavioural therapy
for PTSD in children and adolescents: a preliminary
randomized controlled trial. Journal of the Amer-
ican Academy of Child and Adolescent Psychiatry
46, 1051– 61.

[14] The Pediatric OCD Treatment Study (POTS)
Randomized Trial. (2004) Cognitive-behavior ther-

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43

Parenting Programmes for Conduct
Problems

Stephen Scott1 and Sajid Humayun2

1Institute of Psychiatry, King’s College London, Department of Child and Adolescent Psychiatry,
London, UK
2National Academy for Parenting Research, Institute of Psychiatry, King’s College London, London, UK

EVIDENCE LINKING PARENTING TO CHILD content and delivery of a typical programme
PSYCHOPATHOLOGY is shown in Box 43.1. Most basic programmes
take 8–12 sessions, lasting 1.5–2 hours each.
The finding that parent–child relationship quality Full accounts of programmes are given by the
is associated with aggressive behaviour, conduct developers [3,4].
disorder and delinquency is one of the most
widely reported in the literature, repeatedly found FORMAT OF A TYPICAL SOCIAL
in large-scale epidemiological investigations, LEARNING PROGRAMME
intensive clinical investigations and naturalistic
studies of diverse samples using a mixture of Teaching a child-centred approach
methods [1]. The sort of parenting behaviours The first session covers play. Parents are asked to
associated with these outcomes are high criticism follow the child’s lead rather than impose their own
and hostility, harsh punishment, inconsistent ideas. Instead of giving directions, teaching and
discipline, low warmth, low involvement, low asking questions during play, parents are instructed
encouragement and poor supervision. simply to give a running commentary on their
child’s actions. As soon as the parent complies, the
The link with depression, anxiety and other practitioner gives feedback. After 10–15 minutes,
emotional problems (e.g. somatic complaints, this directly supervised play ends and the parent
social withdrawal) is clear, although smaller than is ‘debriefed’ for half an hour or more alone with
that found for disruptive outcomes [2]. There is the clinician.
also a connection between parenting and quality
of a child’s peer relationships, mediated by social The second session involves elaboration of play
cognitions and behavioural strategies learned skills. The previous week’s ‘homework’ of playing
from interacting with parents (Box 43.1). at home is discussed with the parent in consider-
able detail. Often there are practical reasons for
PROGRAMMES FOR CHILDREN BASED not doing it (‘I have to look after the other children,
ON SOCIAL LEARNING THEORY I’ve got no help’) and parents are then encouraged
to solve the problem and find ways around the dif-
Programmes based on social learning theory have ficulty. For some parents there may be emotional
evolved for more than 40 years and there is a blocks (‘it feels wrong – no one ever played with
large evidence base. Most are aimed at antisocial me as a child’), which need to be overcome before
behaviour as their proximal target outcome. The they feel able to practise the homework.

Child Psychology and Psychiatry: Frameworks for practice, Second Edition. Edited by David Skuse, Helen Bruce,
Linda Dowdney and David Mrazek.
 2011 John Wiley & Sons, Ltd. Published 2011 by John Wiley & Sons, Ltd.

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Parenting programmes for conduct problems

Box 43.1 Features of effective parenting programmes based on social learning
theory

Content
• Structured sequence of topics, introduced in set order during 10—12 weeks
• Curriculum includes play, praise, rewards, setting limits and discipline
• Parenting seen as a set of skills to be deployed in the relationship
• Emphasis on promoting sociable, self-reliant child behaviour and calm parenting
• Constant reference to parent’s own experience and predicament
• Theoretical basis informed by extensive empirical research and made explicit
• Plentiful practice, either live or role-played during sessions
• Homework set to promote generalization
• Accurate but encouraging feedback given to parent at each stage
• Self-reliance prompted (e.g. through giving parents tip sheets or book)
• Emphasis on parents’ own thoughts and feelings varies from little to considerable
• Detailed manual available to enable replicability
Delivery
• Strong efforts made to engage parents (e.g. home visits if necessary)
• Collaborative approach, typically acknowledging parents’ feelings and beliefs
• Difficulties normalized, humour and fun encouraged
• Parents supported to practise new approaches during session and through homework
• Parent and child can be seen together, or parents only seen in some group programmes
• Creche, good-quality refreshments, and transport provided if necessary
• Therapists supervised regularly to ensure adherence and to develop skills

After this discussion, live practice with the child their own, eating nicely, and so on. In this way the
is carried out. This time the parent is encouraged frequency of desired behaviour increases. How-
to go beyond describing the child’s behaviour and ever, many parents find this difficult. Usually, with
to make comments describing the child’s likely directly coached practice, praise becomes easier.
mood state (e.g. ‘you’re really trying hard making Later sessions go through the use of reward charts.
that tower’, or ‘that puzzle is making you really fed
up’). This process has benefits for both the parent Imposing clear commands
and the child. The parent gets better at observing A hallmark of ineffective parenting is a continu-
the fine details of the child’s behaviour, which ing stream of ineffectual, nagging demands for the
makes them more sensitive to the child’s mood. child to do something. Parents need to be taught
The child gradually gets better at understanding to reduce the number of demands, but make them
and labelling his/her own emotional states. much more authoritative. This is done through
altering both the manner in which they are given,
Increasing desirable child behaviour and what is said. The manner should be force-
Praise and rewards are covered here. The parent ful (standing over the child, fixing him/her in the
is required to praise their child for lots of simple eye, and in a clear firm voice giving the instruction).
everyday behaviours such as playing quietly on

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The emotional tone should be calm, without shout- the wider family, school or peer networks. Thus
ing and criticism. The content should be phrased interventions tend to be one of two types:
directly (‘I want you to . . . ’). It should be specific family-based interventions or multicomponent
(‘keep the sand in the box’) rather than vague (‘do interventions.
be tidy’). It should be simple (one action at a time,
not a chain of orders), and performable immedi- Family-based interventions
ately. Commands should be phrased as what the Being based on systemic family therapy theo-
parent does want the child to do, not as what ries, family-based interventions typically attempt
the child should stop doing (‘please speak quietly’ to alter the structure and functioning of the family
rather than ‘stop shouting’). Instead of threatening unit. The best known in the context of delinquency
the child with vague, dire consequences (‘you’re is Functional Family Therapy (FFT) [5]. It is
going to be sorry you did that’), ‘when–then’ com- designed to be practicable and relatively inexpen-
mands should be given (‘when you’ve laid the sive: 8–12 one-hour sessions are given in the family
table, then you can watch television’). home, to overcome attendance problems common
in this client group; for more intractable cases,
Reducing undesirable child behaviour 26–30 hours are offered, usually over 3 months.
Consequences for disobedience should be applied
as soon as possible. They must always be followed There are three phases to treatment; the first
through: children quickly learn to calculate the is the engagement and motivation phase. Here
probability that consequences will be applied, and the therapist works hard to enhance the percep-
if a sanction is given only every third occasion, a tion that change is possible. The aim is to keep
child is being taught he/she can misbehave the rest the family in treatment, and then to move on to
of the time. Simple logical consequences should be find what precisely the family wants. Techniques
devised and enforced for everyday situations (e.g. include reframing, whereby positive attributes are
if a child refuses to eat dinner, there will be no enhanced (e.g. a mother who continually nags
pudding). The consequences should ‘fit the crime’, may be labelled as caring, upset and hurt). The
should not be punitive, and should not be long next phase is not commenced until motivation
term (e.g. no bike riding for a month), as this will is enhanced, negativity decreased, and a positive
lead to a sense of hopelessness in the child, who alliance established.
may see no point in behaving well if it seems there
is nothing to gain. Consistency of enforcement The second phase targets behaviour change.
is central. There are two main elements to this: communi-
cation training and parent training. This stage is
Time-out from positive reinforcement remains applied flexibly according to family needs. Thus if
the final ‘big one’ as a sanction for unacceptable there are two parents who continually argue and
behaviour. The point here is to put the child in this is impinging on the adolescent, the ‘marital
a place away from a reasonably pleasant context. subsystem’ will be addressed, using standard tech-
Parents must resist responding to taunts and cries niques. Parent training techniques are similar to
from the child during time-out, as this will reinforce those found in standard approaches.
the child by giving attention. Time-out provides a
break for the adult to calm down also. The third and final phase is generalization. Here
the goal is to get the improvements made in a
INTERVENTIONS WITH YOUTH few specific situations to generalize to other simi-
lar family situations and to the wider community.
In adolescence somewhat different approaches are For example, to help the youth and family nego-
necessary, with more emphasis on negotiation and tiate positively with community agencies such as
close supervision when the young person is out of school and to help them get the resources they
the home. Also, whilst many components of pro- need. Sometimes this latter goal may require the
grammes based on social learning theory are incor- therapist to be a case manager for the family.
porated, additional elements may be required. In
particular, there may need to be more of a focus Multicomponent interventions
on the wider systems around the youth, be they These attempt to target multiple risk factors in
multiple domains, with the best known being Mul-
tisytemic Therapy (MST) [6]. The initial focus of

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MST is an assessment that will identify the youth’s MEDIATORS OF CHANGE
difficulties in relation to the wider environment.
Difficulties are understood as a reaction to a In recent years, researchers have begun to inves-
specific context, not seen as necessarily intrinsic tigate the factors that mediate outcome. This
deficits. At the same time strengths will be identi- research helps to identify the ‘active ingredient’
fied that can be used as levers for positive change. of therapy. Both reductions in negative parent-
These may be in the young person, the parents, the ing (critical, harsh and ineffective practices) [11]
wider family, peers, the school or the community. and increases in positive parenting [12] have been
shown to mediate a reduction in child symptoms.
Interventions are designed to promote respon-
sible behaviour and decrease irresponsible DISSEMINATION: THE ROLE
behaviour with the aim of helping the youth OF THERAPIST SKILL
become independent and develop prosocial life
skills. They will be focused in the present and be Therapist performance can be divided into three
action oriented with well-defined specific goals. parts: the alliance, which could be defined as how
This requires daily or weekly efforts by family well, both personally and collaboratively, the client
members, which enables frequent practice of new and therapist get on together; fidelity or adherence
skills, positive feedback for efforts made and rapid to specific components of a model, which concerns
identification of non-adherence to treatment. the extent to which the therapist follows the actions
prescribed in the manual; and the skill or compe-
Intervention effectiveness is evaluated con- tence with which the therapist carries out the tasks
tinually with the intervention team assuming (i.e. how well the therapist performs the actions).
responsibility for overcoming barriers to suc- A meta-analysis of youth studies found that the
cessful outcomes. Whilst the way the therapy is alliance contributed on average an effect size of
delivered is closely controlled, the precise nature 0.21 standard deviations to outcome; this finding
of moment-to-moment interaction is not tightly held across treatment types, and across youth, par-
prescribed. In a sense MST is a set of operating ent and family approaches [13]. In a trial under
principles that draw on the evidence for what- regular clinical conditions [14], therapist skill had
ever works – e.g. cognitive–behavioural therapy a large effect on child outcomes – the worst thera-
(CBT), close monitoring and supervision – rather pist made outcomes slightly worse. These findings
than one specific therapy. have major implications for service delivery, since
they suggest that at least for multi-problem, clini-
EFFECTIVENESS cal cases a high level of therapist skill is required,
and staff training will need to reflect this.
Social learning approaches
Systematic reviews and meta-analyses of studies CONCLUSION
usually with ‘no treatment controls’ confirm that
these approaches work well for antisocial chil- The best parenting programmes incorporate
dren aged 3–10 years [7]. Mean effect sizes across empirical findings from developmental studies and
studies vary from around 0.4 to 1.0 according to are effective in using these to alter dimensions of
outcome, thus showing good effectiveness. parenting, which in turn improve child outcomes.
In future, better assessments of parenting are
Youth interventions needed so that programmes can be tailored to
Adolescents are generally found to do less well specific needs rather than ‘one size fits all’.
in parenting programmes for antisocial behaviour.
However, studies on adolescents generally have REFERENCES
the most severe, persistent cases. When cases of
similar severity are compared directly there is no [1] Denham S, Workman E, Cole P et al. (2000) Pre-
age effect [8]. The results for FFT and MST are diction of externalizing behaviour problems from
reasonably impressive, at least in the USA [9,10]. early to middle childhood: the role of parental
Whilst evaluations outside the USA are either socialisation and emotion expression. Developmen-
lacking or mixed there are currently UK trials of tal Psychopathology 12, 23–45.
these interventions underway.

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Approaches to intervention

[2] Wood J, McLeod B, Sigman M et al. (2003) Par- [9] Woolfenden SR, Williams K, Peat J. (2001) Fam-
enting and childhood anxiety: theory, empirical ily and parenting interventions in children and
findings, and future directions. Journal of Child adolescents with conduct disorder and delin-
Psychology and Psychiatry 44, 134– 51. quency aged 10-17. Cochrane Database of Sys-
tematic Reviews Issue 2. Art. No.: CD003015; doi:
[3] Markie-Dadds C and Sanders M. (2006) Self- 10.1002/14651858.CD003015.
directed triple P (positive parenting programme) for
mothers with children at-risk of developing conduct [10] Littell JH. (2005) Lessons from a systematic review
problems. Behavioural and Cognitive Psychother- of effects of multisystemic therapy. Children and
apy 34, 259–75. Youth Services Review 27, 445– 63.

[4] Webster-Stratton C and Reid J. (2003) The incred- [11] Beauchaine T, Webster-Stratton C, Reid J. (2005)
ible years parenting program. In: Kazdin A and Mediators, moderators and predictors of 1-year
Weisz J (eds), Evidence-Based Psychotherapies for outcomes among children treated for early-onset
Children and Adolescents. New York: Guilford problems: a latent growth curve analysis. Journal of
Press, 224– 40. Consulting and Clinical Psychology 75, 371–88.

[5] Sexton TL and Alexander JF. (2000) Functional [12] Gardner F, Burton J, Klimes I. (2006) Randomised
Family Therapy. Washington, DC: U.S. Department controlled trial of a parenting intervention in the
of Justice. voluntary sector for reducing child conduct prob-
lems: outcomes and mechanisms of change. Journal
[6] Henggeler SW, Rowland MD, Randall J et al. (1999) of Child Psychology and Psychiatry 47, 1123– 32.
Home-based multisystemic therapy as an alternative
to the hospitalization of youths in psychiatric crisis: [13] Shirk S and Karver M. (2003) Prediction of treat-
clinical outcomes. Journal of the American Academy ment outcome from relationship variables in child
of Child and Adolescent Psychiatry 38, 1331– 9. and adolescent therapy: a meta-analytic review.
Journal of Consulting and Clinical Psychology 71,
[7] Maughan B, Denita R, Christiansen E et al. (2005) 452– 64.
Behavioural parent training as a treatment for exter-
nalizing behaviours and disruptive behaviour disor- [14] Scott S, Spender Q, Doolan M et al. (2001) Mul-
ders: a meta-analysis. School Psychology Review 34, ticentre controlled trial of parenting groups for
267– 86. childhood antisocial behaviour in clinical practice.
British Medical Journal 323, 1–7.
[8] Ruma PR, Burke R, Thompson RW. (1996) Group
parent training: is it effective for children of all ages?
Behaviour Therapy 27, 159–69.

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44

Systemic and Family Approaches
to Intervention

Philip Messent

Tower Hamlets Child and Adolescent Mental Health Service, London, UK

INTRODUCTION EXTERNALIZING DISORDERS

The word ‘systemic’ holds many meanings that Attention deficit hyperactivity
have changed and evolved over time according disorder (ADHD)
to historical and political contexts [1]. With prac- Systemic interventions for ADHD comprising
tice ever-changing and evolving, approaches that sessions with families, school staff and young
have been researched are unlikely to be at the cut- people, are best offered as elements of multimodal
ting edge of practice. As Carr [2] notes, most programmes involving stimulant medication [3],
of the approaches researched thus far belong with systemic interventions playing an increasingly
to modernist early systemic approaches rather important role in the longer term [4]. Family
than to later postmodern approaches that are less therapy for ADHD focuses on helping families
amenable to manualizing and randomized con- to develop patterns of organization conducive
trolled trials (RCTs). Modernism here refers to the to effective child management: a high level of
rationalist, materialist and reductionist view that parental cooperation; clear intergenerational
an objective understanding of a shared, universal boundaries; warm, supportive family relation-
and measurable reality is achievable. In contrast ships; clear communication and clear, moderately
postmodernist approaches see our understanding flexible rules, roles and routines [5].
of the world as tentative and provisional, elabo-
rated by individuals within particular communities. Conduct problems in adolescence
Such approaches are inherently sceptical about the Woolfenden et al. [6] found that family-based
universal applicability of any treatment approach. interventions were more effective than routine
treatment – falling on a continuum of care extend-
Research trials assessing the effectiveness of ing from Functional Family Therapy through more
family-based approaches to common problems intensive Multi-Systemic Therapy (MST), to very
exhibited by children and young people have intensive treatment foster care. The first two of
recently been reviewed [2]. Here I focus on the these approaches are discussed elsewhere in this
most promising approaches, before noting evi- volume (see Chapter 43), so I will only discuss here
dence of treatment effectiveness of more recent the third and most intensive of these interventions,
postmodernist practices drawn from a different Multi-Dimensional Treatment Foster Care.
research tradition.

Child Psychology and Psychiatry: Frameworks for practice, Second Edition. Edited by David Skuse, Helen Bruce,
Linda Dowdney and David Mrazek.
 2011 John Wiley & Sons, Ltd. Published 2011 by John Wiley & Sons, Ltd.

276

Approaches to intervention

Multi-Dimensional Treatment Foster Care All of these treatment approaches are labour
(MDTFC): This approach aims to help adoles- intensive: treatment foster care is offered for a
cents with pervasive conduct problems and their period of up to a year, followed by an ongo-
families by linking both to a new and positive ing multisystemic intervention. During a time of
familial system: a treatment foster family. It aims reductions in public services in the UK, evidence
to modify problem-maintaining factors in all drawn from current RCTs will need to provide
systems by placing the adolescent temporarily compelling evidence of effectiveness to justify such
within a foster family in which the foster parents costly investment.
have been trained to use behavioural strategies
to modify the youngster’s deviant behaviour. The Substance misuse in adolescence
goal is to avoid long-term separation so that as Liddle [9] found that family therapy with young
therapeutic progress is made, adolescents spend people who misuse substances was more effective
more time with their natural family. Chamberlain than routine individual or group psychotherapies
and Smith [7] in a review of two studies found in engaging and retaining them in therapy, and in
that compared with care in a group home for improving psychological, educational and family
delinquents, this treatment approach reduced adjustment. Liddle’s version of multidimensional
running away from placement, rearrest rate and family therapy involves assessment and interven-
self-reported violent behaviour. Benefits were due tion in four areas:
to improvements in parents’ skills for managing
adolescents in a consistent, fair and non-violent • the adolescent as an individual and a member of
way, and to reductions in adolescents’ involvement a family and peer network;
with ‘deviant’ peers, with cost savings of $40,000
per case in juvenile justice and crime victim costs. • the parent(s) – both as individual adults and
their roles as mother, father or caregiver;
It is clear that the family-based interventions
described in Wolfenden et al. [6] can be effective • the family environment and family relationships,
with adolescents in contact with juvenile justice sys- as manifested in day-to-day family transactional
tems. The authors note, however, a lack of RCTs patterns;
for family and parenting interventions for children
and adolescents with conduct disorders, who have • extrafamilial sources of influence such as peers,
had no contact with juvenile justice systems [6]. In school and juvenile justice.
addition they point out that in the studies entering
into their review, there was insufficient evidence of Interventions are made within and coordinated
beneficial effects on problem behaviour, parental across domains, with progress in one area or
mental health, family functioning and peer rela- with one person having implications for others.
tions. Long-term follow-up on adult outcomes was Individual meetings with parent(s) and teenager
not available. set the stage for family sessions, and family
meetings may offer content and new outcomes to
Transferability of treatment approaches: The take to meetings with juvenile justice or school
transferability to a UK setting of these mul- personnel. Liddle emphasizes that this approach
tidimensional systemic treatment approaches was developed and tested as a treatment system
developed in the USA has yet to be established. rather than a one-size-fits-all approach [10]. That
In a London borough trial of MDTFC the project is, as a system offering different versions of a
team had great difficulty with respect to two treat- clinical model that vary according to factors such
ment protocol conditions: recruiting two-parent as clinical sample characteristics (e.g. older versus
foster families and persuading adolescents to give younger adolescents), and treatment parameters
up their mobile phones. Holmes et al. [8], however, (e.g. type of clinical setting).
have reported some early positive findings from
this British trial: the social care costs incurred by EMOTIONAL PROBLEMS
the sample children in the first 6 months of the
pilot study were about 15% less than those they Anxiety
had incurred in the 6 months prior to entry. Systematic reviews (e.g. Ref. [11]) show that
a family-based treatment for anxiety disorders
is at least as effective as individual cognitive–
behavioural therapy (CBT) in alleviating

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symptoms of anxiety, and more effective where multidisciplinary psychiatric team [16]. Effective
parents also have anxiety disorders, and in approaches begin with engaging young people and
improving the quality of family functioning. families in an initial risk-assessment process, then
developing a clear plan for risk reduction involv-
Encopresis ing individual therapy for adolescents alongside
In a narrative review of 42 studies McGrath et systemic therapy for members of the family and
al. [12] found that multimodal programmes involv- social support networks. King et al. [17] describe
ing medical assessments and intervention followed a manualized Youth-Nominated Support Team
by behavioural family therapy were effective for approach that involves the young person naming
43–75% of cases. Effective behavioural family four people to be part of their ‘support team’.
therapy involves psycho-education coupled with a This team, which might include individuals in
reward programme. There is some evidence [13] schools, extended family or religious community,
that a narrative approach is more effective than is encouraged to maintain weekly contact with the
a behavioural one. In the former, child symptoms adolescent and themselves receive input aimed at
are ‘externalized’, that is, they are talked about facilitating their understanding of the young per-
in such a way that they are no longer seen as son and their provision of appropriate support.
‘belonging’ to the child. This can help children feel Compared with psychotherapy and antidepressant
less blamed and stigmatized and more in control. medication, this approach led to improvements
In a retrospective study of 108 children with in the level of suicidal ideation for girls, but
soiling problems the 54 who were treated using not significantly for boys. The authors hypoth-
an externalizing approach did better than children esized that because female adolescents tend to
receiving a standard behavioural intervention, perceive higher levels of social support than male
with parents rating the externalizing intervention adolescents and are usually more satisfied with
as much more helpful. the social support they receive from persons in
their lives, the enhanced support system involved
Depression in the intervention would be particularly helpful
Effective family-based interventions for children for female subjects. Their research suggests that
and adolescents with depression aim to decrease outside-the-family supports can be useful for sui-
family stress and enhance social support within cidal adolescents because some parents of suicidal
the family context through the facilitation of clear teenagers have significant difficulties of their own
parent–child communication, the promotion of that interfere with their ability to be supportive.
family-based problem-solving, the disruption of
negative critical parent–child interaction, and the EATING DISORDERS
promotion of secure parent–child attachment. In
a multi-country study comparing psychodynamic Adolescent anorexia nervosa
individual and family therapy interventions for Family therapy approaches here as described by
children aged 9 to 15 years presenting with Eisler [18] involve firstly an ‘engagement’ phase
moderate to severe depression, both approaches making contact with each adolescent’s family
were found to be effective [14]. Over 74% of member and emphasizing a primary task of over-
children in both groups were no longer clinically coming anorexia, rather than understanding its
depressed at post-test, and 81% of the family causes; secondly helping the family to ‘challenge
therapy group were also no longer clinically the symptoms’; thirdly as concerns around eating
depressed at 6-month follow-up. recede, exploring issues of individual and family
development more broadly; and fourthly ending
Attempted suicide with a discussion of future plans. Eisler notes
Family interventions have been found to improve also [18] the usefulness of a multiple family day
the adjustment of adolescents who have attempted programme where different families can meet
suicide [15], while a version of MST adapted and establish group cohesion in a supportive
for such young people was more effective than atmosphere in which new solutions can be tried.
emergency hospitalization and treatment by a
Eisler’s [18] systematic review of 11 family ther-
apy trials for adolescent anorexia nervosa found

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Approaches to intervention

that by the end of treatment between one-half • Giving people back their words: an 11-year-old
and two-thirds of participants had achieved a commented that ‘with her reviewing the stuff I
healthy weight. At follow-up between 60% and said, it just really helped me ‘cause it was in my
90% had fully recovered. This contrasts with the brain more. . .’.
rates of relapse of 25–30% for first in-patient
admission and 55–75% for further admissions. • Externalizing conversations: a mother of an
This evidence is reflected in the National Institute 8-year-old said, ‘What she was doing in terms
for Health and Clinical Excellence (NICE) guide- of how she was phrasing things, because she said
lines [19], which state that: ‘Family interventions ‘‘the worry puts thoughts in your head. . .’’ and
directly addressing the eating disorder should be my son was immediately saying, like echoing back
offered to children and adolescents with anorexia what she was saying, ‘‘the worry does this. . .’’ so
nervosa’. Some caveats are noted by Eisler, how- I was starting to feel that this was looking good.’
ever, including the small number of studies, their [laughs].
methodological limitations, and that there is lit-
tle research comparing family therapy with other Such action-based research can help ensure
treatments. He notes, too, that systematic evalua- that clinicians are attentive to the experience of
tions have largely been confined to family therapy service-users and that their practice is respon-
with a strong ‘structural’ flavour [18]. sive and effective. It also acts as a counterweight
to knowledge derived from the research on tri-
Bulimia als of manualized treatment approaches that have
Two trials of family therapy show it to be more formed the bulk of this chapter. This emphasis on
effective than supportive therapy [20], and as what clinicians bring to their work and how they
effective as CBT interventions [21] that also help learn and develop is an important complement to
parents to work together to supervise the young lessons about effectiveness drawn from larger scale
person to break the binge–purge cycle. quantitative studies. It has long been found that the
specific technique or approach used by therapists
A DIFFERENT SORT OF EVIDENCE is not as important in accounting for effective-
ness as non-specific factors linked to the quality
Narrative/postmodernist family therapists would of the relationship that is developed between
argue that an exclusive reliance on knowledge client (family) and therapist (as evidenced e.g. by
drawn from RCTs of manualized approaches to Chatoor and Krupnick’s [24] review of the lit-
treatment ignores the more ‘local’ knowledge and erature). The responsible and ethical systemic
expertise in managing difficulties developed by practitioner will be able to draw from the research
clinicians, clients, families, services and commu- knowledge base developed for the particular prob-
nities. This can be disempowering and unhelpful lem areas described above, and continue to learn,
to families. Fredman [22], in contrast, illustrates from their practice with individual clients, what
how clinicians’ knowledge and expertise, com- contributes to the development of relationships
bined with specific knowledge gained during the that client families experience as helpful.
therapeutic encounter, can help bereaved families.
REFERENCES
An alternative method of gaining ‘practice-
based evidence’ has been described by Young and [1] Fredman G. (2006) Working systemically with intel-
Cooper [23] whereby families who had received lectual disability: why not? In: Baum S and Lyng-
therapy reviewed tapes of their own clinical ses- gaard H (eds) Intellectual Disabilities: A Systemic
sions. Families were asked to stop the tape at Approach. London: Karnac, pp. 1–20.
‘meaningful moments’ and then interviewed. The
following themes were generated: [2] Carr A. (2009) The effectiveness of family ther-
apy and systemic interventions for child-focused
• Family members commented upon the impor- problems. Journal of Family Therapy 31, 3–45.
tance of their therapist’s stance – e.g. a 14-year-
old commented, ‘I liked hearing that she was [3] Hinshaw S, Klein R, Abikoff H. (2007) Childhood
accepting that if I didn’t want to answer a question attention-deficit hyperactivity disorder: nonphar-
then she would be fine with that. . .’. macological treatments and their combination with
medication. In: Nathan P and Gorman J (eds) A
Guide to Treatments that Work, 3rd edn. New York:
Oxford University Press, pp. 3–28.

279

Systemic and family approaches to intervention

[4] Jensen P, Arnold L, Swanson J, Vitiello B, Abikoff [14] Trowell J, Joffe I, Campbell J et al. (2007)
H, Greenhill L. (2007) 3-year follow-up of the Childhood depression: a place for psychotherapy: an
NIMH MTA Study. Journal of the American outcome study comparing individual psychody-
Academy of Child and Adolescent Psychiatry 46, namic psychotherapy and family therapy. European
989– 1002. Child and Adolescent Psychiatry 16, 157– 67.

[5] Anastopoulos A, Shelton TL, Barkley R. (2005) [15] Harrington R, Kerfoot M, Dyer E et al. (1998) Ran-
Family-based psychosocial treatments for children domised trial of a home based family intervention
and adolescents with attention-deficit/hyperactivity for children who have deliberately poisoned them-
disorder. In: Hibbs E and Jensen P (eds) Psychoso- selves. Journal of the American Academy of Child
cial Treatments for Child and Adolescent Disorders: and Adolescent Psychiatry 37, 512– 18.
Empirically Based Strategies for Clinical Practice,
2nd edn. Washington, DC: American Psychological [16] Huey S, Henggeler S, Rowland M et al. (2004) Mul-
Association, pp. 327–50. tisystemic therapy reduces attempted suicide in a
high-risk sample. Journal of the American Academy
[6] Woolfenden S, Williams K, Peat J. (2002) Family of Child and Adolescent Psychiatry 43, 183– 90.
and parenting interventions for conduct disorder
and delinquency: a meta-analysis of randomised [17] King C, Kramer A, Preuss L, Kerr D, Weisse L,
control trials. Archives of Diseases in Childhood 86, Venkataraman S. (2006) Youth-nominated support
251– 6. team for Suicidal Adolescents (Version 1): A ran-
domised control trial. Journal of Consulting and
[7] Chamberlain P and Smith D. (2003) Antisocial Clinical Psychology 74, 199–206.
behaviour and children and adolescents: The Ore-
gon multidimensional treatment foster care model. [18] Eisler I. (2005) The empirical and theoretical base
In: Kazdin A and Weisz J (eds) Evidence Based of family therapy and multiple family day therapy
Psychotherapies for Children and Adolescents. New for adolescent anorexia nervosa. Journal of Family
York: Guilford Press, pp. 281–300. Therapy 27, 104– 13.

[8] Holmes L, Westlake D, Ward H. (2008) Calculat- [19] NICE. (2004) Eating Disorders: Core Interventions
ing and Comparing the Costs of Multidimensional in the Treatment and Management of Anorexia
Treatment Foster Care, England (MTFCE): Report Nervosa, Bulimia Nervosa and Related Eating Dis-
to the Department for Children, Schools and Fam- orders. London: The British Psychological Society
ilies. Loughborough: Centre for Child and Family and Gaskell.
Research, Loughborough University.
[20] Le Grange D, Crosby R, Rathouz P, Leventhal B.
[9] Liddle H. (2004) Family-based therapies for ado- (2007) A randomised control comparison of family-
lescent alcohol and drug use: research contributions based treatment and supportive psychotherapy for
and future research needs. Addiction 99, 76–92. adolescent bulimia nervosa. Archives of General
Psychiatry 64, 1049– 56.
[10] Liddle H. (2010) Multidimensional Family Therapy:
a science-based treatment system. Australian and [21] Schmidt U, Lee S, Beecham J et al. (2007) A
New Zealand Journal of Family Therapy 31, 133– 48. randomised controlled trial of family therapy and
cognitive behavioural therapy guided self-care for
[11] Barmish A and Kendall P. (2005) Should parents be adolescents with bulimia nervosa and related disor-
co-clients in cognitive-behavioural therapy for anx- ders. American Journal of Psychiatry 164, 591– 8.
ious youth? Journal of Clinical Child and Adolescent
Psychology 34, 569–81. [22] Fredman G. (1997) Death Talk: Conversations with
Children and Families. London: Karnac.
[12] McGrath M, Mellon M and Murphy L. (2000)
Empirically supported treatments in paediatric psy- [23] Young K and Cooper S. (2008) Towards co-
chology: constipation and encopresis. Journal of composing an evidence base: the narrative therapy
Paediatric Psychology 25, 225–54. revisiting project. Journal of Systemic Therapies 27,
67 – 83.
[13] Silver E, Williams A, Worthington F, Philips N.
(1999) Family Therapy and soiling: an audit of exter- [24] Chatoor I and Krupnick J. (2001) The role of
nalising and other approaches. Journal of Family non-specific factors in treatment outcome of psy-
Therapy 20, 413–22. chotherapy studies. European Child and Adolescent
Psychiatry 10, S19–S25.

280

Approaches to intervention

45

Psychotherapeutic Approaches: A
Psychodynamic Perspective

Eilis Kennedy

Tavistock and Portman NHS Foundation Trust, London, UK

INTRODUCTION Where possible the work is undertaken in a
regular consistent setting. When working indi-
An interest in applying psychoanalytic ideas to vidually with young children the psychotherapist
therapeutic work with children and adolescents prepares a box for each child with suitable toys and
arose out of the thinking of Anna Freud and drawing materials to facilitate the child’s creative
Melanie Klein, and received further impetus play, exploration and non-verbal communication.
from work showing the impact upon children of It is usual practice for the child’s parents/carers to
their experiences of separation and loss during attend parallel psychotherapeutic sessions.
the Second World War [1]. Over time psycho-
analytically informed therapeutic approaches The psychotherapeutic model is deeply embed-
have expanded beyond individual work with ded in a developmental approach to children’s
the child to include work with families, groups, difficulties, and an excellent account of a psycho-
parent–infant psychotherapy and parent/couple analytic perspective on personality development
work. This chapter focuses on psychodynamic from infancy to adolescence can be found in
psychotherapeutic approaches to children and Waddell [4]. Increasingly, research from neu-
adolescents presenting with a variety of emotional roscience and developmental psychology is
and behavioural problems. used to complement this model and enhance
understanding of work with children with neu-
BASIC PREMISES OF A PSYCHODYNAMIC rodevelopmental disorders or those who have
APPROACH experienced severe maltreatment [5].

Key concepts guiding the therapeutic process THE EVIDENCE BASE FOR CHILD
include an interest in unconscious processes and PSYCHOTHERAPY
the ‘internal’ world of the child. Children’s play
is thought to provide a window onto the child’s The evidence base for psychodynamic child
unconscious thoughts and feelings. The child’s play psychotherapy is somewhat limited as randomized
and behaviour is therefore used by the therapist to controlled trials (RCTs) have been few in number.
understand the child’s inner world [2]. Attunement A 2004 systematic review identified 32 studies, not-
to the child in order to be receptive to the minutiae ing that many had limitations of study design and
of what is being emotionally exchanged is one of sample size. Only five were RCTs and four were
the primary tasks [3]. The ability to gather fine quasi-RCTs [6]. Though small in number, these
details regarding how the child responds to the latter nine studies represent 33.3% of the total
setting and relates to the therapist is essential. reviewed – a proportion that compares favourably
with the 7.4% of experimental/quasi-experimental

Child Psychology and Psychiatry: Frameworks for practice, Second Edition. Edited by David Skuse, Helen Bruce,
Linda Dowdney and David Mrazek.
 2011 John Wiley & Sons, Ltd. Published 2011 by John Wiley & Sons, Ltd.

281

Psychotherapeutic approaches: a psychodynamic perspective

studies identified in an examination of the Internalizing and externalizing disorders
evidence base for treatments in child mental health Disruptive behavioural disorders: There is
in general [7]. Recent research reviews include limited intervention research in this area, though a
qualitative studies and those focusing on process retrospective study of the case notes of 763
as well as outcome research [8,9]. A National children attending the Anna Freud Centre found
Institute for Health Research (NIHR) multicentre poorer outcomes for those diagnosed with conduct
RCT, comparing cognitive–behavioural therapy, or oppositional defiant disorders [13]. Outcomes
short-term psychodynamic psychotherapy and were, however, better for younger children and
specialist clinical care, in the treatment of adoles- those with mixed emotional and behavioural
cents with major depression, is now underway (see disorders.
the NIHR website: http://www.hta.ac.uk/project/
1731.asp). Internalizing disorders: Research evidence here
suggests that children with depressive and/or anx-
EXAMPLES OF RESEARCH WITH CHILDREN iety disorders respond positively to a psychody-
AND YOUNG PEOPLE PRESENTING WITH namic therapeutic approach.
VARIOUS CLINICAL PROBLEMS
In a quasi-randomized 2-year follow-up of chil-
Children who have experienced dren aged 6–11 years with depressive or anxiety
abuse or neglect disorders, Muratori et al. [14] compared those
While not concerned with assessing the effects of assigned to either a time-limited psychodynamic
psychodynamic interventions per se, an interesting psychotherapy (PP) intervention condition or to
body of work undertaken by Hodges and Steele community services. The results of the study indi-
[10,11] illustrates that it is possible to assess and cated that PP was effective in treating internaliz-
measure changes in the attachment representa- ing disorders at the time of intervention and at
tions of children who have been adopted following 6-month follow-up. A ‘sleeper’ effect for PP was
experiences of abuse and neglect. Using a story also found at 2-year follow-up in so far as only chil-
stem technique, whereby children are presented dren in the PP group moved into the non-clinical
with the beginning of a story relevant to their range on standardized assessments, while those in
experiences and then asked to complete it, Hodges the control group remained at the same level of
and Steele demonstrated that the children’s por- clinical severity.
trayal of attachment figures changed over a 2-year
follow-up period to include more positive repre- A multicentre randomized trial compared
sentations of attachment figures, although earlier focused individual psychodynamic therapy and
negative representations still persisted alongside parallel therapeutic work with parents (FIPP) with
the more positive ones. a systemic integrative family therapy approach
(SIFT), in a sample of children aged 10–14 years
A research project by Trowell et al. [12], on the who met criteria for major depressive disorder
other hand, concentrates on assessing the effec- and/or dysthmia [15]. Significant reductions in
tiveness of two types of interventions for girls disorder rates for both groups were found such
who had been sexually abused. Using an RCT that clinical depression had remitted in more than
design, individual psychotherapy was compared 70% of participants in both types of intervention,
with a psycho-educational group psychotherapeu- and reductions in comorbid conditions were
tic intervention. While both types of intervention evident. Improvements were persistent, with a
were found to be effective at substantially reducing 6-month follow-up indicating that none of the
psychopathological symptoms, and participants in FIPP participants remained depressed, compared
both groups evidenced improved functioning, indi- to 81% of SIFT participants, although the loss of
vidual therapy led to a greater improvement in four cases to follow-up in the SIFT group limited
symptoms of post-traumatic stress disorder. The assessment of effectiveness rates. While the final
authors note that the small sample size, and the outcome of these interventions appears similar, a
lack of a control group limit conclusions about different pattern of responses was found. Family
changes attributable to treatment. work appeared to have highly effective initial
impact, whereas the response to individual work
was slower but possibly more sustained.

282

Approaches to intervention

Mixed diagnoses Young people with poorly controlled diabetes
A number of studies have focused on children Moran and colleagues undertook a series of stud-
presenting in middle childhood with a range of ies assessing the effectiveness of psychoanalytic
difficulties rather than belonging to a particular psychotherapy for children with poorly controlled
diagnostic category. One randomized trial of such diabetes [18,19]. A quasi-randomized study com-
children, aged 5–9 years, compared time-unlimited pared two groups, each containing 11 diabetic
or time-limited (12 sessions) psychodynamically children with unstable insulin-dependent diabetes.
oriented treatment with a minimal-contact control Those in the treatment group received intensive
group (four sessions) [16]. All groups showed sig- psychoanalytic psychotherapy (up to 3–4 times a
nificant improvements from pre-test to post-test, week) for an average of 15 weeks; those in the
though changes in family functioning in the con- control group received only routine psychological
trol group were significantly greater than those input without individual psychotherapy. A signif-
in the time-unlimited group. At 4-year follow-up, icant improvement in diabetic control was noted
all three groups did well on a variety of outcome in the experimental group compared to controls,
measures although the control group did rather with 91% of participants in the treatment group
better, being the only group to report significant showing a reduction in glycosylated haemoglobin
improvements on severity of target problems and in contrast to only 36% of controls. This improve-
measures of family functioning. The researchers ment was maintained at 1-year follow-up.
speculate that the four-session ‘minimal contact
control’ group may have proved most effective As part of this study three children with dia-
because the families’ own capacities for coping betes and growth retardation were studied, using
and resilience had been harnessed. a single-case experimental design methodology; in
all three cases there were gains in height over
A further RCT compared the effectiveness of the predicted height following psychotherapeutic
structural family therapy with individual psycho- treatment [19].
dynamic child psychotherapy and a ‘recreational’
control in boys aged 6–12 years presenting with Long-term outcomes
mixed diagnoses [17]. Attrition was greatest in The Anna Freud Centre long-term follow-up
the control group (43%) and greater in the fam- study:
ily therapy group compared with the individual Adult outcome: In this study [20], the adult
therapy (16% vs 4%). Both family therapy and outcome of 34 children who had received psy-
individual psychodynamic therapy were equally chotherapeutic treatment at the Anna Freud
effective in reducing behavioural and emotional Centre was compared with the outcome of 11
problems on a variety of outcome measures that of their untreated siblings. In general those who
included family systems and individual psycho- had received treatment in childhood were found
dynamic rating scales. Findings on measures of to be functioning well, reporting low levels of
family functioning were mixed: the control group adversity, relatively few severe life events and
showed no significant change; the family therapy good health. They displayed adequate personality
group improved; those receiving individual psy- functioning across a range of domains and a low
chodynamic psychotherapy showed deterioration rate of personality disorders.
at 1-year follow-up. This finding may possibly be
biased as an intention-to-treat analysis was not Interestingly while adversity in childhood was
carried out despite variable drop-outs in the three greater in the treated children, the untreated sib-
groups, but it may also be attributable to the fact lings were found to experience more negative life
that the individual psychodynamic child therapy events in adulthood. In relation to personality func-
was undertaken in the absence of any parallel par- tioning, the entire sample appeared to be doing
ent work, contrary to usual practice. The study well in the work domain. In the area of intimate
underlines the importance of working with the relationships those children successfully treated in
wider family system in conjunction with individual childhood appeared to be doing better than their
work with the child. untreated siblings.

Possible adverse effects of treatment were high-
lighted in relation to attachment security. While
a secure adult attachment status was common in

283

Psychotherapeutic approaches: a psychodynamic perspective

those who had moved from poor functioning in future research. For example, there are indications
childhood to high functioning in adulthood, the that individual psychotherapy undertaken in the
attachment style of those who had been unsuccess- absence of concurrent parent/family work may
fully treated in their childhood was predominantly have a negative impact on family functioning.
preoccupied/entangled. Those children in the sam- There is a suggestion also that unsuccessful
ple who did not receive psychoanalytic treatment treatment in childhood may result in a preoc-
were found to be predominantly dismissing in cupied/entangled attachment style in adulthood.
their adult attachment style. Treated participants In addition some adults who received treatment
demonstrated a balanced and accurate memory of in childhood describe how the treatment itself
their childhood experiences, though in contrast to compounded a sense they had that there was
their siblings, their memories tended to be more ‘something wrong with them’ and for some there
painful. was an anxiety that it may have resulted in a
tendency to be overly introspective.
Patients’ perspectives: Another aspect of this
study assessed the perspective of the patient by CONCLUSION
exploring the memories of adults who were in
therapy as children and examining the meaning The application of psychoanalytic understanding
participants gave to the experience of therapy in to psychotherapeutic work with children has a
the context of their later lives [21]. long tradition. Hopefully this work will continue
to evolve and develop with the contribution of new
Two-thirds of participants were able to describe insights from large-scale treatment trials, develop-
some aspect of the experience of child psychother- mental psychology and neuroscience.
apy that had felt helpful at the time of treatment.
Some were more confident about the positive REFERENCES
impact than others. Several described how being
able to talk and ‘unburden’ themselves was help- [1] Likerman M, Urban E. (2009) The roots of child
ful. One described how the treatment provided a and adolescent psychotherapy in psychoanalysis.
‘sort of canvas’ to ‘express myself in a way that In: Lanyado M and Horne A (eds), The Handbook
I wouldn’t necessarily have been able to talk to of Child and Adolescent Psychotherapy: Psychoan-
anyone else about these problems’. Some noted alytic Approaches, 2nd edn. London: Routledge,
how the therapist’s attention made them feel more pp. 15–26.
confident and how therapy enabled them to cope
better. [2] Lanyado M and Horne A. (2009) The therapeutic
setting and process. In: Lanyado M and Horne A
Others questioned the potentially negative (eds), The Handbook of Child and Adolescent Psy-
impact of the therapy. Some of their comments chotherapy: Psychoanalytic Approaches, 2nd edn.
included feelings that the therapy was ‘pointless’ London: Routledge, pp. 157– 74.
and had made no difference, or that it had set
them apart from others. As one observed ‘the [3] Hunter M. (2001) Psychotherapy with Young Peo-
last thing I wanted was to feel different’. In some ple in Care: Lost and Found. Sussex: Brunner-
participants, this sense of being different created Routledge.
or exacerbated a sense that they were somehow
‘damaged’ and that there was ‘something wrong’ [4] Waddell M. (2002) Inside Lives: Psychoanalysis and
with them. the Development of the Personality, revised edn.
London: Karnac.
POTENTIAL ADVERSE EFFECTS
OF TREATMENT [5] Music G. (2010) Nuturing Natures: Attachment and
Children’s Emotional, Sociocultural and Brain
In contrast to research on pharmacological Development. London: Psychology Press.
treatments there has been a tendency not to look
systematically for adverse effects of psychother- [6] Kennedy E. (2004) Child and Adolescent Psy-
apeutic treatments. However, existing research chotherapy: A Systematic Review of Psychoanalytic
suggests some potential adverse consequences Approaches. London: North Central London Strate-
of treatment that would benefit from scrutiny in gic Health Authority.

[7] Fonagy P, Target M, Cottrell D, Phillips J, Kurtz Z.
(2002) What Works for Whom? A Critical Review
of Treatments for Children and Adolescents. New
York: Guilford Press.

284

Approaches to intervention

[8] Kennedy E and Midgley N. (2007) Process and outcome study comparing individual psychody-
Outcome Research in Child, Adolescent and Parent- namic psychotherapy and family therapy. European
Infant Psychotherapy: A Thematic Review. London: Child and Adolescent Psychiatry 16, 157– 67.
NHS London. [16] Smyrnios K and Kirby R. (1993) Long term com-
parison of brief versus unlimited psychodynamic
[9] Midgley N, Anderson J, Grainger E, Nesic- treatments with children and their parents. Journal
Vuckovic T, Urwin C. (2009) Child Psychotherapy of Consulting and Clinical Psychology 61, 1020– 7.
and Research: New Directions, Emerging Findings. [17] Szapocznik J, Murray E, Scopetta M et al. (1989)
London: Routledge. Structural family versus psychodynamic child ther-
apy for problematic Hispanic boys. Journal of
[10] Hodges J, Steele M. (2000) Effects of abuse on Consulting and Clinical Psychology 57, 571–8.
attachment representations; Narrative assessments [18] Moran G, Fonagy P, Kurtz A, Bolton A, Brook
of abused children. Journal of Child Psychotherapy C. (1991) A controlled study of the psychoanalytic
26, 433–55. treatment of brittle diabetes. Journal of the Amer-
ican Academy of Child and Adolescent Psychiatry
[11] Hodges J, Steele M, Hillman S, Henderson K, 30, 926– 35.
Kaniuk J. (2003) Changes in attachment represen- [19] Fonagy P and Moran C. (1990) Studies of the efficacy
tation over the first year of adoptive placement: of child psychoanalysis. Journal of Consulting and
narratives of maltreated children. Clinical Child Clinical Psychology 58, 684–95.
Psychology and Psychiatry 8, 351– 68. [20] Schachter A, Target M. (2009) The adult outcome of
child psychoanalysis: The Anna Freud Centre long-
[12] Trowell J, Kolvin I, Weeramanthri T et al. (2002) term follow-up study. In: Midgley N, Anderson J,
Psychotherapy for sexually abused girls: psy- Grainger E, Nesic-Vuckovic T (eds), Child Psy-
chopathological outcome findings and patterns of chotherapy and Research: New Approaches, Emerg-
change. British Journal of Psychiatry 180, 234–47. ing Findings. London: Routledge, pp. 144–56.
[21] Midgley N, Target M, Smith J. (2006) The outcome
[13] Fonagy P and Target M. (1994) The efficacy of psy- of child psychoanalysis from the patient’s point of
choanalysis for children with disruptive disorders. view: a qualitative analysis of a long-term follow-
Journal of the American Academy of Child and up study. Psychology and Psychotherapy – Theory,
Adolescent Psychiatry 33, 45– 55. Research and Practice 79, 257– 69.

[14] Muratori F, Picchi L, Bruni G, Patarnello M,
Romagnoli G. (2003) A two-year follow-up of
psychodynamic psychotherapy for internalizing dis-
orders in children. Journal of the American Academy
of Child and Adolescent Psychiatry 42, 331–9.

[15] Trowell J, Joffe I, Campbell J et al. (2007) Child-
hood depression: a place for psychotherapy. An

285

Paediatric psychopharmacology: special considerations

46

Paediatric Psychopharmacology:
Special Considerations

Paramala J. Santosh and Rakendu Suren

Centre for Interventional Paediatric Psychopharmacology, Department of Child and Adolescent Mental
Health, Great Ormond Street Hospital for Children NHS Trust, London, UK

INTRODUCTION • full medical history – current and past;
• detailed medication history, including over-the-
Problems of mental health and behaviour in chil-
dren require a multidisciplinary approach, and counter medications;
optimal treatment is multimodal. The number of • history of substance misuse to ascertain potential
children in the USA taking prescription drugs for
emotional and behavioural disturbances is growing misuse liability and interactions with prescribed
dramatically and has given rise to multiple con- medication;
troversies, ranging from concerns over off-label • detailed family history, including history of men-
use and long-term safety to debates about the tal illness, suicide, substance abuse, neurolog-
societal value and cultural meaning of pharma- ical/medical conditions (especially early-onset
cological treatment of childhood behavioural and coronary artery disease), and the response of
emotional disorders. More than 80% of the world- the family members to psychotropic medication.
wide use of stimulant medications occurs in the
USA, and the use of antidepressants and antipsy- MEDICATION AS PART OF A MULTIMODAL
chotics is many times greater in the USA than TREATMENT PACKAGE
in other countries [1]. Variability in use reflects
differences in diagnostic systems, clinical practice Treatment plans should be individualized accord-
guidelines, drug regulation, health services orga- ing to the pattern of target symptoms and strengths
nization, availability and allocation of financial identified in the evaluation. Treatment should
resources, and cultural attitudes towards child- target situations in which symptoms cause most
hood behavioural and emotional disturbances [1]. impairment, and treatment progress should be
This chapter focuses on aspects of psychopharma- monitored by custom-designed target symptom
cology that have special relevance in children and scales or daily behavioural report cards. The
adolescents; it provides relevant information about designation of a case manager is essential for
classes of medication, rather than disorder-specific chronically disabled individuals to coordinate the
treatment recommendations. wide range of services necessary for their care and
to ensure periodic diagnostic reassessments.

INFORMATION TO ASSIST JUDICIOUS SYMPTOM-BASED
PRESCRIBING PHARMACOTHERAPEUTIC STRATEGY

Apart from a thorough diagnostic assessment, the As pharmacological treatment is symptom based
following information is important: in most psychiatric conditions, it is useful to con-
ceptualize it as described below [2].

Child Psychology and Psychiatry: Frameworks for practice, Second Edition. Edited by David Skuse, Helen Bruce,
Linda Dowdney and David Mrazek.
 2011 John Wiley & Sons, Ltd. Published 2011 by John Wiley & Sons, Ltd.

286

Approaches to intervention

• Symptoms that require and are likely to respond USE OF NON-LICENSED PSYCHOTROPIC
to medication alone: inattention, impulsivity, MEDICATION
hyperactivity, tics, obsessions, psychotic symp-
toms, labile mood. Most psychotropics – other than stimulants, ato-
moxetine for attention-deficit hyperactivity disor-
• Symptoms that are less likely to respond to med- der (ADHD), and imipramine for enuresis – are
ication alone, requiring both medication and not licensed for use in children. Unlicensed psy-
psychosocial interventions: aggression, rituals, chotropics are not contraindicated in children, and
self-injury, depression. doctors can prescribe any medication approved
by the appropriate agency (e.g. the US Food and
• Symptoms that are unlikely to respond to medica- Drug Administration or the European Medicines
tion and need specific remediation: skill deficits Agency), to any age group, if they believe that
in academic, social or sports domain. there is a reasonable clinical indication. Thus,
licensing of medication constrains drug companies
THE ART OF PRESCRIBING MEDICATION but leaves doctors free to prescribe unlicensed
drugs or to use licensed drugs for unlicensed indi-
Besides the neurochemical effect of any given cations. The drug companies are not legally liable
agent, the response to medication also depends if any untoward reaction occurs in children treated
on an inherent ‘placebo response’, as well as the without their knowledge, using such non-licensed
therapeutic concordance achieved by obtaining medication. It is therefore important that the par-
agreement and acceptance of why the medication ents and patients (as appropriate) are given this
is prescribed and what is the expected response. information as part of the informed consent.
Rewards experienced from medication treatment
include improvement in symptoms, school perfor- FACTORS AFFECTING
mance and family relationships, and reduced level PHARMACOTHERAPY IN CHILDREN
of parenting stress. Identified costs include the
impact of adverse side effects, social stigma, lack Understanding the pharmacokinetics and pharma-
of response, fears of addiction, and changes in the codynamics of drugs used in psychopharmacology
child’s personality [3]. Acceptance of the diagnosis across the paediatric age spectrum from infants
influences adherence while medication education to adolescents represents a major challenge for
has varying effects. Families’ attitudes, beliefs and clinicians. In paediatrics, treatment protocols use
perceptions about psychiatric illness and treatment either standard dose reductions for these drugs
play a large role in medication treatment deci- for children below a certain age or use less con-
sions. A trusting relationship with the clinician has ventional parameters such as weight for allometric
a positive effect on adherence, but psychosocial dosing; the rationale behind this, however, is often
treatment alternatives are usually preferred. With lacking.
maturation, adolescents have more influence on
decisions related to adherence [3]. Absorption and hepatic metabolism: The rate of
absorption is faster in children, and peak levels
The above characteristics are enhanced when are reached sooner. Hepatic metabolism is highest
parents and patients feel understood, accept during infancy and childhood (1–6 years), is about
that treatment is necessary and agree with the twice the adult rate in prepubertal children (6–10
prescriber regarding the need for the treatment, years), and is equivalent to that in adults by the age
and when medication is started in small doses of 15 years [5]. This is important clinically because
using the principles of minimum effective dose younger children may require higher doses (mg/kg)
(MED). The MED is the minimum dose with of hepatically metabolized medication, compared
which ‘acceptable’ improvement with minimal with older children and adults.
side effects is achieved. Medication should be
initiated in small doses (usually in doses that are Fat distribution: Substantial fat stores slow the
one-eighth to one-sixth of the final anticipated elimination of highly lipid-soluble drugs (e.g. fluox-
dose), increasing the dosage after about every five etine and pimozide) from the body. Fat distribution
half-lives of the drug – in practice usually every
3–7 days, over a period of 4–6 weeks – to identify
the MED [4].

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