Emotional Problems

The effectiveness of psychological interventions for anxiety disorders, depression and anorexia nervosa will be considered in this section.

Anxiety

While all children have developmentally appropriate fears, some are referred for treatment of anxiety problems when their fears prevent them from completing developmentally appropriate tasks such as going to school or socializing with friends. The overall prevalence for clinically significant fears and anxiety problems in children and adolescents is approximately 2 % to 9 % (Anderson, 1994; American Psychiatric Association, 1994; World Health Organization, 1992). With respect to age trends, simple phobias and separation anxiety are more common among preadolescents and generalized anxiety disorder, panic disorder, social phobia, and obsessive compulsive disorder are more common among adolescents (Klein, 1994).

In a review of evidence from experimental single-case designs and controlled outcome studies King & Ollendick (1997) concluded that exposure based procedures including systematic desensitization and flooding; modelling; contingency management and coping skills training are all effective treatments for childhood phobias. All of these elements have been incorporated along with psychoeducation into a comprehensive programme by Silverman & Kurtines (1999). Following psychoeducation, parents are coached in how to prompt and reinforce their children's courageous behaviour while not reinforcing anxious behaviour. Children are concurrently trained in relaxation and cognitive coping skills. Then children are prompted by parents to expose themselves to feared situations and reinforced by parents for courageous behaviour and for using cognitive coping skills and relaxation to manage their anxiety. Gradually, control over entry into anxiety-provoking situations and reinforcement for managing anxiety in these situations is transferred from the parents to the child who learns self-prompting and self-reinforcement skills. The programme concludes with relapse prevention training. Results of two controlled trials with anxious and phobic children support the efficacy of this treatment package (Silverman and Kurtines, 1999).

Elliott (1999) in a thorough literature review concluded that there is some evidence for the efficacy of behavioural and cognitive-behavioural approaches to school refusal, with effective programmes entailing a high degree of family involvement. For example, Blagg & Yule (1984) found that behavioural family therapy was more effective than a hospital-based multimodal inpatient programme and a home tuition and psychotherapy programme for the treatment of school phobia. Behavioural family therapy included detailed clarification of the child's problem; discussion of the principal concerns of the child, parents and teacher; development of contingency plans to ensure maintenance of gains once the child returned to school; a rapid return to school plan; and follow-up appointments with parents and teachers until the child had been attending school without problems for at least 6 weeks. A year after treatment, 93 % of children who received family-based behaviour therapy were judged to have been successful in returning to school compared with 38 % of children in the multimodal inpatient programme and 10 % of those from the home tuition and psychotherapy programme.

Barrett, Dadds & Rappee (1996) found that a family-based programme for children with severe generalized anxiety problems was more effective than an individual coping-skills training programme. In the family based programme both parents and children attended separate group sessions and some concurrent family therapy sessions and were coached in anxiety management, problem solving and communications skills and the use of reward systems. In the anxiety management sessions parents and children learned to monitor and challenge unrealistic catastrophic beliefs and to use relaxation exercises and self-instructions to cope with anxiety provoking situations. In the problem solving and communication skills sessions, coaching in speaking and listening skills occurred and families learned to manage conflict and solve family problems systematically. In the reward systems sessions, parents learned to reward their children's courageous behaviour and ignore their anxiety-related behaviours and children were involved in setting up reward menus. A year after treatment 90 % of those that participated in the family-based programme were recovered compared with 70 % of those in the individual programme.

Rapoport & Inoff-Germain (2000) concluded from an extensive literature review that cognitive-behavioural programmes, which include exposure and response prevention, relaxation training and coping skills training, especially when coupled with pharmacological intervention with serotonin reuptake inhibitors such as clomipramine hold particular promise for the treatment of obsessive compulsive disorder in children. For example, March, Mulle & Herbel (1994) found that 80% of children with obsessive compulsive disorder (OCD) in a single group outcome study showed clinically significant improvement after treatment and this was maintained at follow-up following a family-based intervention programme and pharmacological treatment with clomipramine. The programme, How I Ran OCD Off My Land (March & Mulle, 1998), was based on Michael White's narrative therapy externalization procedure, exposure and response prevention, relaxation skills training and coping skills training. In the narrative therapy externalization component of the programme the child and parents were helped to view obsessive compulsive disorder as a medical illness separate from the youngster's core identity. Children were encouraged to externalize the disorder by giving it a nasty nickname and to make a commitment to driving this nasty creature out of their lives. They then were helped to map out a graded hierarchy of situations that elicited obsessions and led to compulsions of varying degrees and those situations in which the child successfully controlled these symptoms were noted. These situations were subsequently monitored on a weekly basis because increases in the number of these reflected therapeutic progress. In the behavioural family therapy component of the programme children were coached in coping with anxiety by using self-instruction and relaxation skills. Parents were coached to support and reward their children through the process of facing anxiety-provoking situations while avoiding engaging in compulsive anxiety reducing rituals.

Perrin, Smith & Yule (2000) in their review of the treatment of post-traumatic stress disorders in children and adolescents concluded that there is evidence from a small number of controlled trials for the effectiveness of cognitive behavioural programmes for this disorder. Such programmes begin with psychoeducation and goal setting, following which youngsters are trained in coping and relaxation skills that are subsequently used in exposure sessions. In these sessions therapists facilitate emotional processing of traumatic memories by helping youngsters recall vivid traumatic memories. Treatment programmes conclude with sessions on relapse prevention.

From this cursory review it is clear that effective psychological intervention programmes for anxiety disorders in children and adolescents are family based and include creating a context within family therapy that allows the child to eventually enter into anxiety provoking situations and to manage these through the use of personal coping skills, parental support and encouragement.

Depression

Major depression is a recurrent condition involving low mood, selective attention to negative features of the environment, a pessimistic cognitive style, self-defeating behaviour patterns, a disturbance of sleep and appetite and a disruption of interpersonal relationships (American Psychiatric Association, 1994; Harrington, 1993;Kovacs, 1997; Reynolds & Johnson, 1994; World Health Organization, 1992). In community samples prevalence rates of depression in preadolescence range from 0.5 % to 2.5 % and in adolescents from 2 % to 8 % while 25 % of referrals to child and adolescent clinics have major depression.

There is strong evidence that both genetic and family environment factors contribute to the aetiology of depression (Reynolds & Johnson, 1994). Parental criticism, poor parent-child communication and family discord have all been found to be associated with depression in children and adolescents. Integrative theories of depression propose that episodes occur when genetically vulnerable youngsters find themselves involved in stressful social systems in which there is limited access to socially supportive relationships.

Cognitive behaviour therapy, conjoint family therapy and concurrent group-based parent and child training sessions have all been found to be effective in the treatment of major depression (Harrington etal., 1998; Kazdin & Marciano, 1998). Effective cognitive behaviour therapy programmes include psychoeducation, self-monitoring, cognitive restructuring, coping and relaxation skills training, pleasant activity scheduling and problem-solving skills training. Effective family therapy and family-based interventions aim to reduce the family stress to which the youngster is exposed and enhance the availability of social support to the youngster within the family context. Core features of all effective family interventions include the facilitation of clear parent-child communication, the promotion of systematic family-based problem solving and the disruption of negative critical parent-child interactions.

Anorexia

The prevalence of anorexia nervosa - a syndrome where the central feature is self-starvation - among teenage girls is about 1 % (World Health Organization, 1992; American Psychiatric Association, 1994). Wilson & Fairburn (1998) in a recent extensive literature review concluded that family therapy and combined individual therapy and parent counselling with and without initial hospital-based feeding programmes are effective in treating anorexia nervosa (for example, Crisp etal., 1991;Eisler etal., 1997;Le Grange etal., 1992; Hall & Crisp, 1987; Robin&Siegal, 1999; Russell etal., 1987). They also concluded that inpatient refeeding programmes must be supplemented with outpatient follow-up programmes if weight gains made while in hospital are to be maintained following discharge. Key elements of effective treatment programmes include engagement of the adolescent and parents in treatment; psychoeducation about the nature of anorexia and risks associated with starvation; weight restoration and monitoring; shifting the focus from the nutritional intake to normal psychosocial developmental tasks of adolescence; facilitating the adolescent's individuation and increasing autonomy within the family; and relapse prevention. Structural family therapy (Minuchin, Rosen & Baker, 1978) and Milan systemic family therapy (Selvini Palazzoli, 1978) are the main treatment models that have influenced the types of therapies evaluated in these treatment trails. With respect to service development, available evidence suggests that for youngsters with eating disorders effective treatment involves up to 18 outpatient sessions over periods a long as 15 months. Initial hospitalization for weigh restoration is essential where medical complications associated with weight loss or bingeing and purging place the youngster at risk.

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