Chapter 1: Development

Considerations in Assessment and

Treatment

Amy PrzeworskiKimberly Dunbeck

Importance of Developmental Considerations

Developmental Psychopathology Emphasizes interplay between psychopathology and cognitive, emotional,

social development of children and adolescents Need to consider development during assessment, treatment planning, and

therapy implementation

Development & Diagnostic Criteria Diagnostic criteria typically apply adult criteria to children Some disorders in the DSM-5 include descriptions of child manifestation of

symptoms; few disorders specify symptoms across different ages

Developmental Uniformity Myth Myth states that disorders manifest the same no matter what the age Lack of attention to developmental variations in the DSM are consistent with

this myth despite research that indicates psychological symptoms vary across developmental states

Development and Anxiety Disorders

1. Separation Anxiety Disorder More common in younger children ages 6 to 9 May be related to physical developmental changes

occurring during these ages (e.g., children learn independence from parents from 6 to 11 years old)

2. Social Phobia More prevalent in adolescents May be due to the emphasis adolescents place on peer

relationships and social interactions

Depression

1. Rates• Low rates (less than 2%) in childhood• Increase in adolescence (4% to 8%)

2. Symptoms• Children with first depressive episode before

adolescence tend to have more severe, recurrent, treatment-resistant MDD

• Up to 40% of children who have a depressive episode will have a second episode within 5 years

Bipolar Disorder

1.Rates• Rare in young children• 15 to 19 years of age typical age of onset

2.Symptoms• Child-onset Bipolar more chronic and treatment

resistant than later onset

Multimethod Assessment

1.Children are less likely to see their symptoms as causing functional impairment.

• Parents or other reporters more likely to see impairment

2.Despite need for multimethod assessment, rarely agreement on symptoms.

• E.g., children report anxiety symptoms at higher rates and intensity parents

• Kappas for parent-child agreement range from .09 (depression) to .32 (anxiety) and .29 (ADHD)

Parent vs. Child Report: Implications for Child Age

1. Parent Report• Some suggest that parental report should be relied on for children

below age of 11 (Achenbach et al., 1987 Ollendick & Hersen, 1993)

2. Self-Report• Not recommended for children under 8 because typically unable to

complete measures without assistance (Beidel & Stanley, 1993)• Different questionnaire formats (e.g., using pictorial Likert scale)

can help children as young as 4 years old accurately complete assessments (Lagattuta et al., 2012)

Assessment of Risk: Alcohol

1. Alcohol• Consumption common in late adolescence: 4 out of 5

12th graders report drinking alcohol• 50–62% 6th graders report tasting alcohol

• Only 29% have had more than a sip• 4th grade: 10% of children more than one sip

2. Assessment• Even if child below drinking age, do not assume not

drinking• Asking is recommended with children after age 11

Assessment of Risk: Smoking and Illicit Drugs

1. Cigarettes• 60% of high school seniors have smoked cigarettes;

one third have done so in the previous month

2. Drugs• 50% of high school seniors have used illicit drugs (other

than alcohol and nicotine) at some time in their lives (Johnson et al., 2002)

3. Assessment• Be sure to ask adolescents about nicotine and drug use• Strong association between drug use and

psychopathology (Deas & Brown, 2006)

Assessment of Risk: Sexual Behavior

• 21% of adolescent males report having sex by the age of 15 and 7.2%–10% by the age of 13 (Albert et al., 2003)• Similar rates found in female adolescents

• Close to 50% of high school students have sex before they graduate• Significantly higher rates in African American high

school students (89% males, 70% females)• African American and Latino teens report higher rates

of sexual behavior at earlier ages than Caucasians (Kann et al., 1998)

Assessment of Risk:Contraception

1. Contraception• 57–74% of adolescents report they used contraception

at their first sexual experience• Only 10–20% of adolescents who are having sex use

condoms consistently • Numbers lower in adolescents of diverse ethnicities

• Adolescents typically have multiple sexual partners over short periods of time

2. Assessment• Important to ask about sexual behavior and

contraception due to the high prevalence

Treatment

Most validated treatment option for children

and adolescents is Cognitive Behavioral Therapy (CBT)

• Used with 4 to 18-year-olds • Techniques vary with the age and developmental level

of the child

Perspective Taking

Young Children Children between 2 and 3 years old describe basic feelings (e.g., sadness,

anger) Unable to understand that people have feelings and thoughts separate from their

own (Dunn et al., 1991) Therapy techniques that require children to think about the impact of their

behaviors on others may not be as effective (Selman, 1980)

School-Age Children Begin to understand that others see things differently and others may hold

different opinions than their own Opposing thoughts and feelings of others, however, are considered wrong

because they differ from their own

Adolescence Understand that others’ thoughts and feelings, while different than their own, are

not wrong and represent an equally valid perspective (Chandler, 1988)

Problem Solving

Cognitive restructuring: numerous ways to interpret a situation, and it is one’s interpretation that influences emotional response to a situationImportant component of CBTLimited perspective taking abilities of children below late childhood

may make it challenging to identify alternative explanationsCan be difficulty for children to implement

Before 14 years oldDifficult for child to understand and generate multiple solutions

without significant scaffolding (Sternberg & Nigro, 1980)Limitation is important when implementing cognitive restructuring May be easier to identify positive or negative aspects of a situation

Abstract Reasoning

Abstract ReasoningNot consistently developed until ~15 years old (Piaget,

1970)Limits ability to role-play and brainstorm about possible

outcomes (Weisz, 1997)Important component of CBT

Approach in Developmental Sensitive MannerE.g., children as young as 3 years old have hypothetical

reasoning capability as long as future oriented (e.g., “What if something different happened next time?)

Causal Reasoning

Understanding complex cause and effect relationships (e.g., between thoughts, behaviors, and emotions)

Young children struggle to connect past events with current emotions or thoughts

Connecting past with present unsuccessful with young children (Shirk, 1988)

Young children typically will attribute events to conscious, concrete reason or outside forces as opposed to psychological or internal experiences

Emotional Understanding

Young Children (Less than 3 years old)Able to identify primary emotions: happiness, anger,

sadness, fearDefine emotional experiences by outside behavior

(Nannis & Cowan, 1987) • E.g., child may state that a person is happy only if the individual is

smiling

Therapists can teach young children to recognize their own emotional experience by thinking about their facial expression and convey these emotions using words

Emotional Understanding

School-age Children (6–10 years old)Begin to see emotions as internal events that can be shared externally

with others or kept a secretCan recognize that emotional experiences can be caused by external

events (Nannis, 1988)Around age 8, children understand the emotional experiences of others

better and recognize the same situation can lead to different reactions in different people (Gnepp & Klayman, 1992)

By 11 or 12, children can understand they have control over their emotions and can hide or control them (Nannis & Cowan, 1987)

TherapyCan understand most CBT techniques (e.g., linking antecedent events,

emotions, behaviors)Most CBT packages designed for children 7–12 years old (e.g., Sanders,

1999)

Language

Be aware of child’s language abilities Therapist should use vocabulary that the child understands

(Weisz & Weersing, 1999)Will vary by age and across children

Emotional competence may be intertwined with the ability to use emotion-descriptive language (Beck et al., 2012)

Children become better at perspective taking as they acquire a more sophisticated vocabulary, particularly verbs (Astington et al., 2005)

Language level will impact therapist’s ability to utilize role-playing and other social problem-solving techniques

Therapy Format

Role of the ParentChildren linked to their parents since they rely on parents

for all of their basic needs, as well as many of their social and emotional needs

The younger the child, the more important the parents’ involvement in therapy• E.g., Children aged 7–10 years old benefited from family

involvement in CBT but addition of family component was not more beneficial than individual CBT for children aged 11–14. Adolescents showed better treatment response to individual CBT than individual CBT with parent training (Cobham et al., 1998)

Therapy Format

Group TherapyFor children can be beneficial, particular for social skills

and building social connections and friendships (Larson & Lochman, 2010)

Not ideal for addressing conduct or delinquency problems• Deviancy training: tendency for antisocial teens to encourage and

reinforce antisocial tendencies

Activity in Therapy

Important to keep children engagedTeaching concepts (e.g., coping skills, cognitive

restructuring, emotional awareness) needs to be accomplished through concrete means

Examples: Puppets: demonstrate skills, externalize problem, play

various roles relevant to the child’s life “Quick Decision Catch” (Pincus et al., 2011): children and

the therapist pass a ball and give a solution to a problem quickly when they catch the ball. Once solutions have been generated, child chooses best solution.

Summary

Many developmental considerations in the assessment and treatment of childrenParental involvement, use of group therapy, implementation of

games or activities

To make clinical work relevant to children of all ages, clinicians need to be sensitive to cognitive, social, and emotional developmental stage of client

Implementing various developmental considerations clinicians can be better prepared to offer efficacious assessment and treatment