Evidence-Based Practice with Emotionally Troubled Children and Adolescents

Morley D. Glicken

• Publisher: Academic Press
• Year: 2009
• Print ISBN: 9780123745231
• eBook ISBN: 9780080923062
• Topic: Psicologia
• Subtopic: Psicologia clinica

This book on evidence-based practice with children and adolescents focuses on best evidence regarding assessment, diagnosis, and treatment of children and adolescents with a range of emotional problems including ADHD; Bi-Polar Disorder; anxiety and depression; eating disorders; Autism; Asperger's Syndrome; substance abuse; loneliness and social isolation; school related problems including underachievement; sexual acting out; Oppositional Defiant and Conduct Disorders; Childhood Schizophrenia; gender issues; prolonged grief; school violence; cyber bullying; gang involvement, and a number of other problems experienced by children and adolescents. The psychosocial interventions discussed in the book provide practitioners and educators with a range of effective treatments that serve as an alternative to the use of unproven medications with unknown but potentially harmful side effects. Interesting case studies demonstrating the use of evidence-based practice with a number of common childhood disorders and integrative questions at the end of each chapter make this book uniquely helpful to graduate and undergraduate courses in social work, counseling, psychology, guidance, behavioral classroom teaching, and psychiatric nursing. - Fully covers assessment, diagnosis & treatment of children and adolescents, focusing on evidence-based practices - Offers detailed how-to explanation of practical evidence-based treatment techniques - Cites numerous case studies and provides integrative questions at the end of each chapter - Material related to diversity (including race, ethnicity, gender and social class) integrated into each chapter

Chapter 1. The Current State of Assessment, Diagnosis, and Treatment of Children and Adolescents with Social and Emotional Problems

At a time when increasing numbers of children are being diagnosed and treated for emotional problems, the unsettling thought of misdiagnosing children who need help but are not being served because of racial and gender issues, and treatment of large numbers of children who are, in reality, responding in normal ways to maturational and social changes has begun to capture a great deal of attention in the popular and professional literature.

Unlike most adults, young children are often unable or unwilling to talk about their symptoms, leaving mental health professionals to rely on observation and information from parents and teachers, which may be incorrect or biased. Because children develop so quickly, what may look like attention deficit disorder in January may seem like something else or perhaps nothing at all in the summer. So subjective is the process of evaluating the problems encountered by children that the trial and error search for a diagnosis and treatment often ends with serious errors. Also, adult diagnoses are often used in lieu of diagnostic categories for children (US Department of Health and Human Services, 2000).

The Surgeon General's Report (US Department of Health and Human Services, 2000) suggests that many human service professionals prefer not to use a diagnosis with children because “[m]any of the symptoms, such as outbursts of aggression, difficulty in paying attention, fearfulness or shyness, difficulties in understanding language, food fads, or distress of a child when habitual behaviors are interfered with, are normal in young children and may occur sporadically throughout childhood” (Chapter 3).

Contrary to the current practice of assigning a diagnosis indicating serious emotional problems using adult diagnostic categories, the Surgeon General's Report (US Department of Health and Human Services, 2000) wisely cautions clinicians about the use of adult diagnostic categories by noting that:

Well-trained clinicians overcome this problem by determining whether a given symptom is occurring with an unexpected frequency, lasting for an unexpected length of time, or is occurring at an unexpected point in development. Clinicians with less experience may either over-diagnose normal behavior as a disorder or miss a diagnosis by failing to recognize abnormal behavior. Inaccurate diagnoses are more likely in children with mild forms of a disorder (Chapter 3).

Yet the problem of misdiagnosing children seems more serious than ever, with new and increasingly arcane diagnostic categories developing that suggest the existence of very large numbers of American children with emotional problems. Some commonly diagnosed mental disorders in younger children include attention deficit hyperactivity disorder (ADHD), depression, anxiety, and oppositional defiant disorder (ODD). The DSM-IV (American Psychiatric Association, 1994) says that ODD exists if a child demonstrates four of eight of the following behavior patterns: “(a) often loses temper; (b) often argues with adults; (c) is often touchy or easily annoyed by others; (d) and is often spiteful or vindictive.” (p. 93). These behaviors are characteristic of many children and adolescents and would not, in and of themselves, give most children an accurate diagnosis of oppositional defiant disorder.

Attention deficit disorder is perhaps the most common diagnosis used with children. Questions used to determine ADHD, such as “Does the child have difficulty in sustaining attention, following instructions, listening, organizing tasks? Does he or she fidget, squirm, impulsively interrupt, leave the classroom?” are such common behaviors, particularly in boys, that one might ask why attention disorder is a diagnosis given to boys at a rate twice that of girls when the rates, medically speaking, are the same.

More troubling is the finding regarding serious mental disorders. Carey (2007) reports that the number of American children and adolescents treated for bi-polar disorder increased 40-fold from 1994 to 2003, and has certainly risen further since 2003. According to Carey, in studies of doctors in private or group practice in New York, Maryland and Madrid, the numbers of visits in which doctors recorded diagnoses of bi-polar disorder increased from 20000 in 1994 to 800000 in 2003, about one percent of the population under age 20. Carey (2007, p. 1) also notes that:

According to government surveys at least six million American children have difficulties that are diagnosed as serious mental disorders, a number that has tripled since the early 1990s even though one of the largest continuing surveys of mental illness in children, tracking 4500 children ages 9 to 13, found no cases of full-blown bi-polar disorder and only a few children with the mild flights of excessive energy that could be considered nascent bi-polar disorder. Moreover, the symptoms diagnosed as serious emotional problems in children often bare little resemblance to those in adults. Instead, children's moods often flip on and off throughout the day, and their upswings often look more like extreme agitation than bi-polar disorder.

In an interview with Judith Rapoport, chief of child psychiatry at the National Institute of Mental Health, Dess (2000) asked if childhood onset schizophrenia is on the increase. Rapoport responded that in 8 years, NIMH had identified only 55 cases of early childhood schizophrenia and notes that they are looking hard to find other cases to provide additional information on the early physical and emotional markers of schizophrenia, a disease usually associated with late adolescence.

However, in studies reported by the Medical College of Wisconsin (2003) the reported the use of certain psychotropic medications in 2–4-year-olds rose threefold between 1991 and 1995. One of the reasons for this increase, according to the report, may the growing acceptance and misuse of psychotropic medications with children. The mounting pressure for children to conform to social standards of good behavior may also contribute to this increase. School administrators play a critical role in determining which children are seen as having emotional problems in need of treatment. However, as the above report argues, “it is not their responsibility, nor do they have the training, to recommend or mandate the use of medications as a solution to behavior problems” (p. 1).

Coyle (2000) reports that the use of psychotropic medications in very young children in two Medicaid programs and a managed care organization suggests that 1–1.5% of all children 2–4-years old enrolled in these programs are currently receiving stimulants, antidepressants, or antipsychotic medications. According to Coyle (2000), since there is no empirical evidence to support psychotropic drug treatment in very young children and there are valid concerns that such treatment could have serious negative side effects on the developing brain, he suggests that limited reimbursements for mental health services to children by many state Medicaid programs “are now increasingly subjected to quick and inexpensive pharmacologic fixes as opposed to informed, multimodal therapy associated with optimal outcomes. These disturbing prescription practices suggest a growing crisis in mental health services to children and demand more thorough investigation” (p. 1).

These concerns are compounded by continuing problems providing needed services to troubled groups of children because of race, gender, and ethnicity. The US Department of Health and Human Services (2000) indicates that Black and Hispanic youths comprise 32% of the general population but approximately 60% of the youth within detention and secure settings. Research by Cross et al. (1989) suggest that African American youth are less likely to receive treatment prior to coming into the system, and when identified in the community are more likely than their Caucasian counterparts to be referred to juvenile justice as opposed to mental health settings.

According to Puzzanchera et al. (2003), rates of incarceration among females are increasing at a faster rate than for males. Odgers et al. (2005) believe that girls within correctional settings “are often more likely than boys to suffer from a number of disorders, including: depression, anxiety and PTSD and (that those problems) increase exponentially for girls within juvenile justice settings; leading some to suggest that a gender paradox exists whereby girls at the most extreme end of the continuum with respect to behavioral and mental health profiles are filtered into correctional settings” (p. 28).

O’Neill (2000) describes an educational crisis for boys in which glaring discrepancies exist in reading, writing, and math scores at grades three and six, suggesting that boys will do badly in high school and higher education. In discussing male under-performance, O’Neill (2000) writes, “We have created a monster which is very difficult to escape from. There is nobody who is going to stand on a platform and start talking about the problems that face young boys, especially if it means criticizing the kind of education policies that got us into this position in the first place” (p. 54). O’Neill believes that those policies have worked against the best interests of boys by creating an educational system in which the primary focus is on the achievement and learning styles of girls, creating an atmosphere in which boys think no one cares about them.

The end result of educational discrepancies affecting boys is that women receive an average of 57% of the bachelor's degrees and 58% of all master's degrees in the United States or, 133 women are getting B.A.s for every 100 men, a number that will increase to 142 women per 100 men by 2010, according to the US Education Department. If current trends continue, there will be 156 women per 100 men earning degrees by 2020 (Conlin, 2003). The discrepancy in male educational achievement raises the issue of an economic imbalance that could create, “societal upheavals, altering family finances, social policies, and work-family practices” (Conlin, 2003, p. 77).

According to Conlin, men are dropping out of the work force, abandoning children, and removing themselves from community involvement. Since 1964, the rate of decline of men voting in presidential elections is twice that of the rate of women. More women now vote than men. As the decrease in men with comparable credentials and earning power continues, increasing numbers of women will, in all probability, never marry. Currently, 30% of all African American women 40–44 years of age have never been married (Conlin, 2003, p. 77). As women pull further ahead of men, the lack of availability of suitable men will reduce the probability of forming families.

In further concerns about the way boys are dealt with, Forbes (2003) suggests that boys are experiencing a severe crisis, which hampers their development and can be harmful to others. Forbes blames this crisis on restrictive male norms which:

… pressures male youths to prove their masculinity through stoic inexpressiveness and control, avoidance of qualities considered to be feminine, homophobia, competition, domination, and aggression. Influential and highly visible institutions, such as the government and the media, tend to favor male values such as aggression as a means to solve problems. Equally problematic is that male youths often grow up without adequate emotional and conceptual tools that enable them to distance themselves from the norm and become conscious of their own development. Recent incidents of schoo...

Table of contents

• Cover Image
• Table of Contents
• Preface
• Acknowledgement
• About the Author
• Chapter 1. The Current State of Assessment, Diagnosis, and Treatment of Children and Adolescents with Social and Emotional Problems
• Chapter 2. Understanding Evidence-Based Practice
• Chapter 3. The Importance of Critical Thinking in Evidenced-Based Practice
• Chapter 4. Diagnosis and Assessment: An Evidence-Based Approach Using the Strengths Perspective with Children and Adolescents
• Chapter 5. Evidence-Based Practice and the Troubled Families of America's Children and Adolescents
• Chapter 6. Evidence-Based Practice with Children and Adolescents Experiencing Educational Problem
• Chapter 7. Evidence-Based Practice with Children and Adolescents Experiencing Social Isolation and Loneliness
• Chapter 8. Evidence-Based Practice with Depression and Suicidal Ideation in Children and Adolescents
• Chapter 9. Evidence-Based Practice with Children and Adolescents Experiencing Anxiety
• Chapter 10. EBP with Child and Adolescent Eating Disorders
• Chapter 11. Evidence-Based Practice with Children and Adolescents Who Abuse Substances
• Chapter 12. Evidence-Based Practice with Gay, Lesbian, Bisexual and Transgender Children and Adolescents
• Chapter 13. Evidence-Based Practice and Attention Deficit Hyperactivity Disorder (ADHD)
• Chapter 14. Pervasive Developmental Disorders: Autism, Asperger's Syndrome, and Pervasive Developmental Disorder-Not Otherwise Specified
• Chapter 15. Evidence-Based Practice with Serious Emotional Problems of Children and Adolescents
• Chapter 16. Evidence-Based Practice with Serious and Terminal Illness, Disabilities and Bereavement in Children and Adolescents
• Chapter 17. Evidence-Based Practice with Spoiled Children and Cyber-Bullies
• Chapter 18. Evidence-Based Practice with Children and Adolescents Coping with Abuse and Neglect
• Chapter 19. Evidence-Based Practice and Sexual Violence by Children and Adolescents
• Chapter 20. Evidence-Based Practice and School Violence
• Chapter 21. Oppositional Defiant and Conduct Disorders Leading to Anti-Social Behavior and Violence
• Chapter 22. Evidence-Based Practice and the Effectiveness of Indigenous Helpers, Mentors, and Self-Help Groups with Children and Adolescent Health and Mental Health Problems
• Chapter 23. Evidence-Based Practice and Resilient Children and Adolescents
• Chapter 24. Needed Changes to Improve the Lives of Children
• Index