child and adolescents

Piaget Stages of Child Development

Sensorimotor (0-2 years): Learns through senses and actions, like touching, looking, mouthing

Preoperational (2-7 years): Developing language and using symbols, egocentric thinking

Concrete Operational (7-11 years): Thinking more logically about concrete events, understanding conservation

Formal Operational (12+ years): Developing abstract and hypothetical thinking, considering the future and moral issues

Attachment styles

Secure attachment

Anxious attachment (Anxious-preoccupied)

Avoidant attachment (Dismissive-avoidant)

Disorganized attachment (Fearful-avoidant)

Attachment Based Interventions

• Creating a secure base in therapy

• Interplay between therapist and family, therapist sharing hypotheses and family discussing them

• Creating genograms

• Discussing present and past episodes of conflict

Still face experiment

• Distress demonstrated by infants when their parent/caregiver suddenly becomes unresponsive

• Demonstrates innate understanding of social interaction for infants and the need for attentive care and connection

MCABFT- Middle Child Attachment Based Therapy

·      evidence based that “promotes secure attachment by interrupting negative parent-child interactions with child that feels distress, replacing with secure based parenting.”

·      Secured based-script: 1) Child express distress, 2) Parent notices the distress, 3) Parent provides support and helps reduce child’s stress.

·      Adapted from work with depressed/suicidal adolescents

·      5 tasks: relational reframe, building alliance with child, building alliance with parents, repairing parent-child attachment & master new communication patterns.

·      Done through primarily through play

Right brain characteristics

Emotional intelligence, nonverbal cues, creativity

Left brain characteristics

Logical, organizational, analytical thinking

Higher Brain

• Upstairs/cerebral cortex & various parts

• Use of logic, regulating emotions

Lower Brain

• Downstairs/brain stem & limbic region/amygdala

• Instincts, basic functions, rapid reactions

Whole Brain Child Integration Strategies

• Connect and redirect: Connect with right brain emotions and redirect to left brain

• Name it to tame it: going through narrative multiple times to better understand the world & themselves

• Engage but don’t enrage: negotiations with distressed child

• Use it or lose it: Brain exercises, emotional regulation, self understanding, empathy, morality

• Move it or lose it: exercise can calm the brain

Role of play for children

• Playing attends to the deep emotional needs we each have at birth

• Creates attachment/bonding/social connections, kids look for emotional connection through play

• Primal urge to play in childhood (Subcortical layers in brain), fosters happy and creative adult brains

• Play behavior is rewarded w/ opioids and dopamine

Implicit vs. Explicit Memories

• Implicit memory is unconscious, automatic recall (like riding a bike), while explicit memory is conscious, intentional remembering (like recalling facts or events).

• Explicit memory involves facts (semantic) and experiences (episodic), requiring effort to retrieve;

• implicit memory (procedural memory) involves skills, habits, and priming, operating without conscious thought. 

Priming Strategies

• Using the “remote” of the mind to replay memories and reinforce previous skills/lessons learned

• “remember to remember”, Making recollections a part of family life

Mindsight Strategies

• Letting “emotional clouds” roll by, teaching that feelings come and go

• SIFT: Sensation, images, feelings, thought; paying attention to what is going on internally

• Going back “the hub”-emotional regulation

Integrating the “Me” and “We” Strategies

• Interpersonal integration

• Making it a point to appreciate each member of the family, increasing family fun

• Connection through conflict–teaching kids to argue with the “we” in mind

Helping children deal with grief

• Kids grieve differently, mood shifting, playing to defend, regression

• Answer childrens’ questions about death

• Developmentally appropriate information

• Giving kids the choice to attend the funeral

Developmental manifestations of grief

• before 3 years: Sense of absence, object permanence developed at 6-12 months

• Preschooler: Talking about death, but expectation that they will come back

• 5 years: Don’t realize that all people die, including self

• 9-10 years: Understanding death as final, irresverible, and inescapable

• Adolescents: Feeling of helplessness/frightened, retreat to childhood, suppress emotions, ability to think abstractly with spirituality

Behavioral Manifestations of Grief

• Angry outbursts, irritability, sleep/eating disorders, difficulty in school, persistent questions about details of death, falibility, psychosomatic ailments, nightmares, temporary regression, shock

• Adolescents: anger to counteract helplessness

Divorce in Families w/ Children and Adolescents

• Emotional trauma before, during, and after

• Risk factors: poverty, less education, adult/children of divorce, has a child with a chronic illness/MH disorder

• Children's external distress-adjustment to new living arrangements, parental tension, alienation

• chronic exposure to high conflict is detrimental

School Aged Kids Distress in Divorce

• Self blame

• Fantasizing about parental reunion

• Lower academic performance

• Mood changes

• Abandonment

Adolescent Distress

• Understanding but difficulty accepting it

• Filling adult roles

• De-idealizing parents

• behavioral changes: aggression, withdrawal, substance abuse, inappropriate sex, poor academic performance

• Suicidal ideation

Prevention of Distress in Divorce

• Awareness of stressors

• Understand child’s experience

• Meet with parents and plan for child care

• Give space to child’s emotions

• avoid putting child in the middle

• parental signatures for care

Neurobiology of ADHD

·       effects prefrontal/frontal lobe- in charge of “executive functioning”—inability to compare past events to present events or plan for future (time)

·       Inability to delay responds (thinking before acting)/self-regulation impaired

Treating children with ADHD

• Multimodal approach, collaborate with medical & school system

• Refer for medical evaluation and possible meds

• Conduct comprehensive assessment

• use DSM dx, check for comorbid conditions

• Psychoed for family about ADHD

• Parental traning to help manage child’s behaviors

Family Therapy for Child and Adolescent Eating Disorders Overview

·      Family Therapy for adolescent anorexia nervosa (FT-AN) and Family Therapy for adolescent bulimia nervosa (FT-BN) are the strongest evidenced based treatments for eating disorders.

·      FT-AN= Strong efficacy with higher rates of recovery at 6-12month follow-up (compared to individual therapy)

·      FT-BN= was found to be superior to cognitive behavioral therapy (CBT)

·      Multi-family therapy formats: Bringing several families (5 -7) together for group therapy is growing in efficacy. (NOT ALONE); Pscyhoed, using more experienced families to share their path, & “hothouse” (intensive tx)

Family Therapy Treatment of Anorexia Phases

FT-AN core features:

1)    Working with family to help child recover

2)    FAMILY IS NOT seen as the cause of the problem

3)    Early in treatment expecting parents to take the lead in managing child’s eating

4)    Externalizing the eating disorder (Narrative Therapy)

5)    Shifting focus on to adolescent/family developmental life cycle

FT-AN Four Phases of Treatment

Phase 1: Alliance building (Multidisciplinary team-medical, individual frame, cognitive frame & family systems frame)

-Psycho-ed re: EFFECTS OF STARVATION

-EXTERNALIZING/blame reduction (Narrative Therapy)

-Meal Plan/prescription (FOOD IS MEDICINE)

 Phase 2: Helping Family Manage Eating Disorder:

-encouraging parents to take lead with eating

-weighing patient at every visit-exploration of what happens at meal times: parental roles, challenging beliefs about difficulties of parental action, sharing what order families’ experiences.

-T has good engagement with adolescent

- physical issues 1^st

-may use Attachment Therapy or EF

Phase 3: Exploring Issues of Individual and Family Development

  -handing back age-appropriate responsibility to the patient

  -refocusing on individual and family needs

  -addressing EFFECTS of eating disorder (Causes DISRUPTION in families)

 -address dependent relationship of family on therapist

Phase 4: Termination

  -future plans/discharge

  -parental anxiety

  -relapse prevention

Family Therapy Treatment of Bulimia

Separated sessions (with adolescent & parents)

-T engagement with adolescent—motivation to change

-Psycho-education

-Practical parenting skills/coaching

-Reducing-criticism, blame & guilt

-Support behavioral change

Family Therapy Treatment of EDs Research Outcomes

• Behavioral Family Systems Theory (BFST)- better weight outcomes & re-start of menstruation

• Family-Based Treatment (FBT)- increased partial and full remission

• FBT-BN- better than supportive psychotherapy, more improvement at end

• FT does improve outcomes of hospitalized/non hospitalized adol.

• Therapist have to have EXPERTISE in area to be EFFECTIVE

• Maternal Criticism-poorer outcomes, Individual Tx better//Paternal Criticism poor outcome regardless of modality

LGBTQ+ Families of Origin

·      Rejection from Family of Origin: primary cause of psychosocial stress among LGBTQ+ people—depression, PTSD & suicide ideation/attempts

·      Depression rates higher—due to CHRONIC STRESS- discrimination, rejection & negative experiences

·      Many LGBTQ+ people may be forced to look outside F of O for support (Chosen Family); Chosen family may still contribute positively (but not statistically significant/temporary)

·       F of O is important for Mental Health (M.H.); ONLY significant predictor of depression levels.

·  Increase in F of O support, decrease in depression and vice versa.

Treating LGBTQ+ children/adolescents in Family Therapy

a)     CREATING REFUGE- safe space, without -ISMS, + reframes, psychoeducation

b)    DIFFICULT DIALOGUES- Meaning & truth/Increase Intimacy/ OFF- Track parenting/LOVE

c)     Nurturing QUEERNESS- Accepting, expanding worldviews, tolerating dissonance of queer differences

Symptoms Linked to Bullying

Anxiety, depression, low self-esteem, SI & long-term MH consequences in adults

Family Based Interventions for Bullying

1-    Educate/empower client

2-    directly address bullying

3-    Identify risk factors

4-    Provide positive parenting techniques

5-    Promote empathy/respect/non-violence

6-    Strengthen family dynamics

7-    Collaborate with School

Individual Risk Factors for Adolescents

• Belief that aggression is legitimate and acceptable

• Abuse (physical, sexual, or emotional)

• ADHD, impulsivity

• poor grades

• antisocial behaviors

• learning disabilities

• hopelessness

• childhood trauma

• low self-esteem

Family Risk Factors for Adolescents

• strongest predictor of violence

• Poor supervision

• conflict/DV

• disruptions/instability

• lack of connection

• parental M.H

• parental criminal history

• sexual abuse

• harsh punishment

• aggression/family violence or antisocial behaviors

Peer Risk Factors for Adolescents

• Delinquent peers

• gangs

• substance abuse in peers

• violent/weapon carrying/criminal peers

• peer pressure

School Risk Factors for Adolescents

• Disengaged

• drop-out

• academic failure

• truancy

• disruptive in class

• grade retention

• negative school climate

• involved in aggression/bullying/fighting

Community Risk Factors for Adolescents

• High crime

• drugs

• poverty

• guns

• violence

• lack of community cohesion

• disorganized

Societal Risk Factors for Adolescents

• low SES

• -ISMs

• immigration issues

• homophobia

Individual Protective Factors

• Hopefulness

• optimism

• empathy

• Strong ethnic identity

Family Protective Factors

• Positive family relationships

• warmth

• Parental expectation of academic achievement

Peer Protective Factors

• Prosocial peers

• Involved in positive activities/clubs

• Being invited to peers’ homes

School Protective Factors

• Safe school environment

• Student/teacher engagement

• Connected atmosphere

• Positive physical environment

• Principal with positive leadership

• clear rules/expectations/order

• supportive atmosphere

Family Therapy Interventions for At Risk Adolescents

·      Strength based therapy/positivity/supportive

·      Positive reframing/non judgmental

·      Restoring Hierarchy

·      Reconnect family/improve communication

·      Empathy

·      Report if necessary to keep safe

·      Invite family members who are often left out

·      Give homework to help bonding b/w family members

·      Reach out to school & community systems

·      Empower them/don’t fix

Four Factors of Teen Violence

1-    DEVALUATION-Situational (Abuse/Neglect/Abandonment/Divorce/Peer Rejection) & Societal (Disrespect—ISMS related to Race, Gender, SES, LBGTQ+)

2-    Disruption of COMMUNITY-3 types: 1) Families (Abuse/Neglect/Divorce/Death), 2) Extended Communities: neighbors, school, church (Natural disasters/Isolation/Bullying), 3) Cultural Communities:like Race/Gender/SES etc. (ISMs)

3-    LOSS of Hero, romantic relationship, parent, home (moving), friendship, money, health(disability)---can be due to abandonment, death & neglect

4-    RAGE- as a threat, as defense, or to violence/to unhealthy relationship

Counteracting Devaluation in Adolescents at Risk

1-    Adults withhold the ‘C’ reactions—challenging, confronting, criticizing and correcting”

2-    “High doses of affirmation, nurturance, and consideration for the person’s dignity & humanity”

3-    VCR APPROACH: Validation/understanding—as much as kid needs, Challenging/confronting—strength based/positive, Requesting

Restoration of Community for Adolescents at Risk

1-    Parents’ responsibility to FIX—help to gain insight, know their teens world/spend time, be vulnerable, take responsibility for wrong doings, listen, use VCR, see the good, negotiate, NEVER GIVE UP!!

2-    Therapy—establish ALLIANCE & Conduct FAMILY THERAPY; Get to know teen, encourage teen to make CONTACT with parents, prepare them for conjoint therapy, negotiate with them-empathy, hope & nurture relationship

3-    Create/encourage/make connections with Extended Family/Schools, Churches, etc…helping schools have appropriate rules of behavior

Rehumanizing Loss with Adolescents at Risk

1-    ACKNOWLEDGE LOSS- relational process

2-    making a loss genogram

3-    Ceremonies, tributes & provocative aids (music)

Rechanneling Rage with Adolescents at Risk

1-    Identifying & inviting—importance/listening/tolerating

2-    Validating—being with, allowing, externalizing

3-    Rechanneling rage—something healthy

Immigration Legal Statuses

• Undocumented

• Liminal (temporary residency)

• Deferred action for childhood arrival (DACA/Dreamers)

• Legal permanent resident

• Naturalized US Citizen

Clinical Guidelines Working with Immigrant Children

• Importance of empowerment and trust built in the space

• don’t instill fear

• Create a concrete plan for deportation; uncertainty makes it worse

• Helping them rebuild community despite fears

• Can focus more on the emotions once they are 9-12+

Impact of Immigration on Family Dynamic

• Children often become parentified, do adult tasks that their parents don’t have access to you

• Parents are no longer able to work and provide for the family

• Impact of separation: long-term trauma, brain changes, developmental delays, increased fear/anxiety, disordered conduct, lack of secure base

Risks with Youth in Foster Care

• More likely to experience trauma (ex: neglect, parental substance abuse, physical abuse, inadequate housing, incarcerated parents, sexual abuse

• 10x more likely to have a mental Dx

• 3x more likely to have chronic stress, leads to ulcers

• Attachment issues

Systemic risk factors for suicidal behavior

• Illness (mental, physical, or substance abuse)

• Personal factors: social support, attitude toward suicide

• Stressful life events, like loss

• Cultural environment & economics

• Access to lethal methods

Systemic risk factors for self harm

• Parental problems (legal and financial)

• Disruptions in upbringing, such as marital problems and divorce

• Relationship problems with family

• Mental health factors, such as hopelessness and depression

Individual risk factors for suicide

• Deficits in problem solving, fewer alternatives and less versatile

• High impulsivity–most attempts are unplanned, considered from 15 mins to 3 hrs

• Hopelessness and low self esteem

• Anger & hostility–conduct disorder/antisocial disorder

• Psychiatric disorders (including substance abuse and depression)

• Disturbed family relationships/interpersonal/peer relationships

• “Copycat effect” from suicides in the media

Family risk factors for suicide

• Family conflict

• Low family cohesion

• High stress environment

• Disconnection + loneliness

Individual risk factors for self harm

• Emotionally vulnerable/sensitive

• Emotional dysregulation

• Acting impulsively

• Unable to self sooth

• Self critical/self loathing

• Inability to name feelings, can’t address them properly

• Mood dependency, inability to alter mood to get things done

Family based therapy for suicidality

• not standard treatment for children/adolescents w/ suicidality, but a promising intervention

• Involvement of caregiver in Tx

• Strengething youth-caregiver relationships

• Enhancing coping skills

Treatment for self harm

• Problem solving skills

• Emotional time outs, stopping to breathe

• Identify and label feelings, slow down and lessen feelings

• STOP skill: Stop, Take a step back, Observe, Proceed

• Reframing emotions

• Opposite action in response to feeling