Clinical Child and Adolescent Psychology

clinical psychologists have worked with children and adolescents since the inception of the field

The first psychological clinic focused on the assessment and treatment of children with learning and behavioral problems

along with the rest of the profession

clinical child psychology has grown tremendously

The Society of Clinical Child and Adolescent Psychology (Division 53 of the APA)

– Currently has a membership in the thousands

– Many graduate programs train psychologists specifically to work with children and adolescents

Clinical child psychologists engage in

assessment, therapy, research/training, and academia

assessment

Often regarding problems related to behavioral, emotional, or intellectual functioning

therapy

This could be working with children and/or their families

academia

Sometimes have the combination of applied and academic roles

some disorders are especially common among children

attention-deficit/hyperactivity disorder (ADHD), conduct disorder, oppositional defiant disorder, and separation anxiety disorder

Children and adolescents can also be diagnosed with disorders that are common among adults

major depression, posttraumatic stress disorder, anorexia, bulimia, substance use, adjustment disorders, phobias, generalized anxiety disorder, etc

In some cases, diagnostic criteria are adjusted for children

Major depressive disorder

– In children and adolescents, irritable mood can replace depressed mood

– Failure to gain weight according to growth expectations can replace weight loss

• PTSD

– Has a distinct set of criteria for children 6 years old and younger

» e.g., diminished interest in playing or playing that involves reenactment of the trauma

Some clinical psychologists divide children’s problems into two broad categories

externalizing and internalizing disorders

externalizing disorders

disorders in which the child “acts out” and often becomes a disruption to parents, teachers, or other children

• These include ADHD, conduct disorder, and oppositional defiant disorder

internalizing disorders

disorders that involve maladaptive thoughts and feelings more than disruptive outward behavior

• These include depression and anxiety disorders

Why do some children develop psychological disorders whereas other children do not?

– This is an essential question for clinical child psychologists

– Children from similar environments can have very different kinds or degrees of psychological and/or behavioral problems

Resilience

the tendency to remain psychologically healthy despite the presence of risk factors that contribute to psychological problems in others

Vulnerability

The tendency to experience psychological problems in the presence of risk factors

factors that contribute to vulnerability to psychological problems

• environmental factors

• parental factors

• child (internal) factors

environmental factors

poverty, serious emotional conflict among parents, single parenthood, an excessive number of children in the home, neighborhood or community factors, and poor schooling

parental factors

poor parental physical health, poor parent mental health, low parent intelligence quotient (IQ), and hypercritical tendencies in the parent

child (internal) factors

medical problems, difficult temperament, low IQ, poor academic achievement, and social skills deficits

The more psychological problems parents have

the more psychological problems their children are likely to have

Breaux et al., 2014

• Assessed parents and kids (at ages 3, 4, 5, and 6)

• Kids whose parents had a mental health illness at age 3 were more likely to have a mental health illness themselves as they got older

– This relationship was especially true when the parent's diagnosis was ADHD, depression, an anxiety disorder, or a personality disorder

Hudson et al., 2014

• Studied children being treated for anxiety disorders

• Children were much less likely to have a diagnosis both immediately after treatment and 6-months after treatment if their parents were non-anxious (in comparison to anxious)

Sibling relationships are also important factors in

kids’ vulnerability to psychological factors

Buist et al., 2013

• Conducted a meta-analysis of 34 studies on the effect of sibling relationships on children’s mental disorders

• Found that those with warmer and more loving brothers and sisters had fewer internalizing and externalizing disorders

• Those whose relationships with siblings were full of conflict were more likely to have both categories of disorders

Grotberg (2003) studied children who were able to thrive in risky environments in which many of their peers struggled

– Sorted differentiating factors into three categories

• External supports

• Inner strengths

• Interpersonal problem-solving skills

In Grotberg’s study, each child was assigned a kid-friendly label

• “I Have” (external supports)

• “I Am” (inner strengths)

• “I Can” (interpersonal and problem-solving skills

I Have (external supports)

• People in my family I can trust and who love me

• People outside my family I can trust

• Limits to my behavior

• People who encourage me to be independent

• Good role models

• Access to health, education, and other services I need

• A stable family and community

– I Am (inner strengths)

• A person most people like

• Generally a good boy/girl

• An achiever who plans for the future

• A person who respects myself and others

• Caring towards others

• Responsible for my own behavior

• A confident, optimistic, hopeful person

I Can (interpersonal and problem-solving skills)

• Generate new ides or new ways to do things

• Work hard at something until it is finished

• See the humor in life

• Express my thoughts and feelings

• Solve problems

• Manage my behavior

• Ask for help when I need it

It matters whether children believe they can change their personality traits

a child’s implicit theory can be fixed or malleable

fixed implicit theory

“I’m shy and there’s nothing I can do about it”

– Often called an “entity” theory

malleable implicit theory

“I’m shy but I can overcome it”

– Often called an “incremental” theory

A “fixed” approach is more likely to lead to mental health problems

Schleider et al. (2015)

• Conducted a meta-analysis of 17 studies on kids aged 4-19

• Found that kids who held a fixed/entity theory had more frequent and more severe psychological diagnoses than those who held a malleable/incremental theory about themselves

any assessment must adopt a

developmental perspective

Developmental perspective

an essential aspect of clinical child psychology whereby clinicians understand the child’s behavior within the context of the child’s developmental age

Problems of childhood may take on different meanings and require different interventions depending upon their

commonality at a given age

An extensive amount of background information might be relevant

This can help the psychologist appreciate the full set of circumstances in which the child’s presenting problems have emerged

Schroeder & Gordeon (2002) have some suggestions

the presenting problem, development, parents/family, environment

the presenting problem

What, exactly, is the presenting problem? Do all parties (parents, child, teachers, etc.) agree on the definition of the problem? When did the problem arise? For whom is this problem most troubling?

development

What is the child’s current state of physical, cognitive, linguistic, and social development? Have there been any developmental abnormalities during childhood or during the prenatal period? Has the child reached all developmental milestones at the expected points in time?

parents/family

What are the relevant characteristics of the child’s parent or parents? What style of parenting is used? What parent factors (psychological, medical, other) might play a role in the child’s problem? How might siblings, grandparents, or other family members influence the child?

environment

What is the child’s larger environment outside the family? What relevant ethnic or cultural factors play a role in the child’s behavior? Are there recent major events in the child’s life that may factor into the current problem

A clinical child psychologist may receive different answers from different people in the child’s life

For this reason, it’s important to rely on more than one source of information

Merrell (2008) advocates a…

Multisource, Multimethod, Multi-setting approach

• An approach involving multiple sources of information, multiple methods of obtaining information, and multiple settings in which information is solicited

Multisource

involves parties such as parents, relatives, teachers, and the child

Multi-method

Involves the use of different methods of data collection such as interviews, pencil-and-paper instruments, and direct observation

Multi-setting

• Sometimes children’s problems pervade all facets of their lives

• Sometimes children’s problems are specific to certain situations

• For this reason, it’s wise to get data from the home, school, clinician's office, and any other relevant setting

Interviews

– When assessing an adult, the adult is often the only person with whom the psychologist speaks

– This is very different in child assessment

• The clinical psychologist typically interviews anyone who, by virtue of their contact with the child, can shed light on the child’s problem

• Parents and teachers are the most common

• May also include siblings, grandparents, other relatives, pediatricians, friends, child-care workers, tutors, etc

Behavioral Observations

When a child’s behavior can be directly observed (as in most externalizing disorders) child clinical psychologists do so

Behavioral observation

the direct systematic observation of a client’s behavior in the natural environment

• Also known as naturalistic observation

Several published systems of observation can be used

e.g., the Direct Observation Form, the Child Behavior Checklist, the Student Observation System, the Behavior Assessment System for Children, the Dyadic Parent-Child Interaction Coding System, the Social Interaction Scoring System, etc

Behavior rating scales

standardized forms that parents, teachers, or other adults complete regarding a child’s presenting problems

– Typically consists of a list of items describing behaviors and a range of responses

• e.g., “The child pushes other children” – very frequently, frequently, sometimes, infrequently, and very infrequently

– Scores are then summed across subscales

• This allows the clinical child psychologist to compare responses with norms from other children of the same age

Advantages of behavior rating scales

Convenience, inexpensiveness, objectivity

Disadvantages of behavior rating scales

• Respondents are restricted from elaborating on their responses

• Scale items may not adequately capture the child’s problem behaviors

Self-Report Scales

– Any assessment scale completed directly by the client

– Require a certain reading level, attention span, and motivation for the child to complete

• For this reason, they are more commonly used with adolescents than with younger children

– These are like those used with adults

• The Minnesota Multiphasic Personality Inventory (MMPI) and Millon Clinical Multiaxial Inventory (MCMI) both have adolescent versions

Projective/Expressive Techniques

– These include many of the same tests used with adults

• The Rorschach Inkblot Method

• The Thematic Apperception Test (TAT)

• Sentence-completion techniques

– The Children’s Apperception Test

• This is an adaption of the TAT test for children

• Features animal, rather than human, characters

2002 survey of members of the APA Division 53 (Clinical Child Psychology)

– Interviews were used far more commonly than any specific assessment technique

– Among non-interview techniques

• Greater reliance on self-report measures for adolescents

• Greater reliance on behavior rating scales for younger children

– Completed by parents or teachers

– The use of some tests (e.g., the WISC) is relatively common

• A significant amount of variation remains

In what ways does psychotherapy with children and adolescents differ from psychotherapy with adults?

The techniques used by both types of therapists often originate from the same underlying theories

– Major approaches to therapy have generated applications for children as well as adults

• These include psychodynamic, humanistic, behavioral, and cognitive orientations

However, children should not be mistaken for miniature adults

Many factors may differ

– Willingness to be in therapy

– Motivation to change

– Ability to sit relatively calmly

– Ability to express feelings for prolonged periods of time

When working with an adult, the client is typically the only one involved in sessions

– Children don’t come to therapy alone

• Parents, relatives, teachers, etc. may be involved

– This means that you’ll need to form more than one alliance

Cognitive-Behavioral Therapies for children

ex: Bravery Bingo, Mr. OCD

More deliberate reinforcement for homework assignments is often done

• e.g., stickers, candy, privileges, praise, etc.

Bravery Bingo (Pincus et al., 2011)

Here, a phobic child earns a token, to be placed on a bingo board, for each successful exposure on the anxiety hierarch

Mr. OCD (Pincus et al., 2011)

• Here, children practice cognitive restructuring by refuting a puppet (Mr. OCD) who exhibits flawed logic

– “A monster’s gonna get you tonight when you’re sleeping” could be countered with “A monster has never gotten me before, and it’s not gonna happen tonight, either! There are no monsters in my room!

Social skills training

a cognitive-behavioral approach in which therapists teach kids behaviors that improve their interactions with others

social skills training works well for kids with a wide range of problems

Used most often in kids who have autism spectrum disorder, social anxiety disorder, or ADHD

social skills training targets many skills

• How to start a conversation

• How to join other kids who are already interacting

• How to express feelings appropriately

• How to handle frustration

• How to manage eye contact and other nonverbal behavior

• How to manage volume and tone of voice

social skills are

• Modeled by the therapist and reinforced during the session

• Reinforced with rewards that are meaningful to the child

Applied behavioral analysis

a behavioral approach that relies heavily on operant conditioning principles (i.e., reinforcement, punishment, shaping, and extinction)

applied behavioral analysis is an evidence based therapy for children with autism spectrum disorder

most commonly utilized and recommended therapy for this disorder

In applied behavioral analysis therapists first help the child identify and define very specific behaviors to target

• Goal could be to increase the frequency (e.g., eye contact or using the toilet)

• Goal could be to decrease the frequency (e.g., injuring himself or others)

In applied behavioral analysis a frequency goal is met then in the child’s environment (and at the child’s pace) the behavior is subjected to consequences through contingency management

The child receives rewards and punishments effective in changing the behavior in the desired direction

Play Therapy

• Unique to child clients

• Typically used with younger clients (preschool or elementary-school age)

• Allows children to communicate via actions with objects rather than with words

– e.g., dollhouses, action figures, and toy animals

Through play

Children can reveal to clinical psychologists their emotional concerns and attempt to resolve them

Three basic functions in play therapy (Brems (2008

– The formation of important relationships

– The disclosure of feelings and thoughts

• e.g., expressing emotions, acting out anxieties

– Healing

• e.g., acquiring coping skills, experimenting with new behavior

Play therapy is psychodynamic

– The playroom usually contains a variety of objects with which the child can choose to play

– Therapists may take note of the objects the child chooses… especially if he or she appears to identify strongly with a particular toy

– The interpretations the therapist offers the child about his or her actions can

• Help make the child aware of inner mental processes

• Increase the child’s ability to make deliberate choices about behavior in the future

Play therapy is humanistic

Rather than interpreting clients’ behavior, humanistic play therapists tend to reflect their client’s feelings

• These may be expressed either directly or indirectly through their play activities