Chapter 15 Treatment of Psychological Disorders 2013 W. W.
Norton & Company, Inc. Gazzaniga Heatherton Halpern FOURTH
EDITION Psychological Science
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15.1 How Are Psychological Disorders Treated? Distinguish
between forms of psychotherapy. Describe the major categories of
psychotropic drugs. Identify alternative biological treatments for
mental disorders. Distinguish between specialized mental health
practitioners.
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How Are Psychological Disorders Treated? Psychological
disorders need to be managed over time through treatment Treatment
depends on the type and severity of symptoms as well as on the
diagnosis Most mental disorders can be treated in more than one way
Psychologists use two basic categories of techniques to treat
mental disorders: psychological and biological
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Psychotherapy Is Based on Psychological Principles
Psychotherapy generally is aimed at changing patterns of thought or
of behavior It has been estimated that there are more than 400
approaches to treatment Many therapists follow an eclectic approach
and use a variety of techniques The relationship between the
therapist and the client is known to affect the outcome of
therapy
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Psychodynamic Therapy Focuses on Insight Freud and Breuer
pioneered the method of psychoanalysis Treatment involved
uncovering unconscious feelings and drives that gave rise to
maladaptive thoughts and behaviors Techniques included free
association and dream analysis General goal of psychoanalysis is to
help clients gain insight into their unconscious and how these
processes affect daily functioning, thus freeing them from these
unconscious influences Contemporary therapists examine patients
needs, defenses, and motives as a way of understanding why theyre
distressed Psychodynamic therapy has become increasingly
controversial (expensive, time consuming, scant evidence of
effectiveness) Proponents argue that this short-term psychodynamic
therapy can be useful for treating certain disorders
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Health Benefits of Talking and Expressing Emotions Researchers
have found positive health effects for people who disclose
emotional events College students who were randomly assigned to
write about an emotional event visited the university health center
fewer times than students assigned to write about other topics,
even though there were no group differences in how often the
students visited the health center before participating in the
study (Pennebaker & Beall, 1986). Talking or writing about
emotionally charged events reduces blood pressure, muscle tension,
and skin conduction during the disclosure and immediately
thereafter Improves immune function, even in people with HIV
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Humanistic Therapies Focus on the Whole Person The goal of
humanistic therapy is to treat the person as a whole, not as a
collection of behaviors or a repository of repressed thoughts
Client-centered therapy encourages people to fulfill their
individual potentials for personal growth through greater self-
understanding Therapists strive to create a safe and comforting
setting for clients to access their true feelings, to be empathic
and to accept the client through unconditional positive regard
Therapist will use reflective listening, in which the therapist
repeats the clients concerns to help the person clarify his or her
feelings Motivational interviewing has proven to be a valuable
treatment for drug and alcohol abuse, as well as for increasing
both healthy eating habits and exercise (Burke, Arkowitz, &
Menchola, 2003)
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Cognitive and Behavioral Therapies Target Thoughts and
Behaviors Behavior therapy: Behavior is learned and therefore can
be unlearned through the use of classical and operant conditioning
Social skills training: Client learns appropriate ways to act in
specific social situations Learn through modeling Cognitive
therapy: Distorted thoughts produce maladaptive behaviors and
emotions; treatment strategies attempt to modify these thought
patterns Forms: Cognitive restructuring Rational-emotive therapy
Mindfulness-based therapy Cognitive Behavioral Therapy (CBT)
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Cognitive Behavioral Therapy While neuroscientists look for the
cause of schizophrenia in the brain, psychologists are looking for
ways other than medication to help people make sense of and deal
with the voices they hear. And as this ScienCentral News video
reports, a therapy adopted in Britain seems to have the
answer.
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Group Therapy Builds Social Support Group therapy rose in
popularity after World War II There were many different stresses
related to the war, with more people needing therapy than there
were therapists available to treat them Advantages: Group therapy
is often significantly less expensive than individual treatment
Group setting provides an opportunity for members to improve their
social skills and learn from one anothers experiences Many groups
are organized around a particular type of problem (e.g., sexual
abuse) or around a particular type of client (e.g., adolescents).
Therapy may be highly structured, or a more loosely organized forum
for discussion.
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Family Therapy Focuses on the Family Context According to a
systems approach, an individual is part of a larger context where
changes in individual behavior will affect the whole system Some
therapists insist that family members be involved in therapy, where
all family members involved in therapy are considered as the client
Example: A childs defiant behavior has led to conflict between
parents. Treatment involves not only working on the childs
behavior, but also helping the parents learn to resolve their
conflict The level of expressed emotion from family members
corresponds to the relapse rate for patients with schizophrenia
(Hooley & Gotlib, 2000)
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Culture Can Affect the Therapeutic Process Culture has multiple
influences on the way psychological disorders are expressed, which
people with psychological disorders are likely to recover, and
peoples willingness to seek help Many Chinese distrust emotional
expression and avoid seeking help for depression, anger, or grief
(Magnier, 2008) In India, a corps of health counselors was trained
to screen for psychological disorders but because of the cultural
stigma of mental disorders, terms such as mental illness,
depression, and anxiety were avoided; terms such as tension and
strain were used instead (Kohn, 2008) Culture plays a critical role
in determining the availability, use, and effectiveness of
different types of psychotherapy for various cultural and ethnic
groups living within any country
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Medication Is Effective for Certain Disorders Drugs that affect
mental processes are called psychotropic medications Anti-anxiety
drugs: used for the treatment of anxiety One class of anti-anxiety
drugs is benzodiazepines Increase the activity of GABA Induce
drowsiness and are highly addictive Antidepressants: used for the
treatment of depression Monoamine oxidase (MAO) inhibitors
Tricyclics Selective serotonin reuptake inhibitors (SSRI)
Antipsychotic/neuroleptics
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Alternative Biological Treatments Are Used in Extreme Cases
Treatment-resistant people cannot be treated successfully with
psychotherapy, medication, or both combined Alternative treatments
include: brain surgery, the use of magnetic fields, and electrical
stimulation Many early efforts reflected crude attempts to control
disruptive behavior: Trepanning Psychosurgery (prefrontal
lobotomy)
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Electroconvulsive Therapy Electroconvulsive therapy (ECT): a
procedure that involves administering a strong electrical current
to the patients brain to produce a seizure Effective for some cases
of severe depression The procedure was developed in Europe in the
1930s and tried on the first human in 1938; commonly used in the
1950s and 1960s to treat some psychological disorders The general
public has a very negative view of ECT ECT now generally occurs
under anesthesia, with powerful muscle relaxants to eliminate motor
convulsions and confine the seizure to the brain
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Transcranial Magnetic Stimulation During transcranial magnetic
stimulation (TMS), a powerful electrical current produces a
magnetic field (about 40,000 times Earths magnetic field) When
rapidly switched on and off, this magnetic field induces an
electrical current in the brain region directly below the coil,
thereby interrupting neural function in that region Single-pulse
TMS: Disruption of brain activity occurs only during the brief
period of stimulation Repeated TMS: Multiple pulses of TMS occur
over extended period TMS may be useful for depression
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Deep Brain Stimulation Deep brain stimulation (DBS): Electrodes
are surgically implanted deep within the brain; mild electricity is
then used to stimulate the brain at an optimal frequency and
intensity DBS has been tremendously successful in treating
Parkinsons disease DBS is being tested for treating other
disorders, including mental disorders such as severe OCD and
depression
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Therapies Not Supported by Scientific Evidence Can Be Dangerous
Most psychologists recommend treatments that careful empirical
research has shown to be effective Unfortunately, many available
therapies have no scientific basis, including ones in which people
re-enact their own births, scream, or have their body parts
manipulated Some treatments believed to be effective are
counterproductive: Encouraging people to describe their experiences
following major trauma Scaring adolescents away from committing
crimes Having police officers run drug education programs such as
DARE Using hypnosis to recover painful memories These methods not
only lack adequate evidence but also may produce results opposite
to those intended (Hines, 2003; Lilienfeld, 2007)
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A Variety of Providers Can Assist in Treatment for
Psychological Disorders Providers range from those with limited
training (e.g., former addicts who provide peer counseling) to
those with advanced degrees in psychopathology Most therapeutic
techniques used have emerged from psychological laboratories
Choosing the right therapist is difficult but extremely important
for ensuring successful treatment One of the central problems with
treating psychological disorders is that there simply are not
enough people available to provide traditional one-on-one
psychotherapy to all who need it Technology-based treatments
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Tongue Mouse Can Control a Wheelchair or Computer Imagine
changing channels or surfing the Web with just a flick of your
tongue. Researchers have developed such a device. As this
ScienCentral News video shows, the system holds the most promise
for those who are paralyzed.
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15.2 What Are the Most Effective Treatments? Identify the
treatments that are most effective for specific psychological
disorders.
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What Are the Most Effective Treatments? Certain types of
treatments are particularly effective for specific types of mental
disorders Scientific studies of treatment indicate that although
some mental disorders are quite easily treated, others are not:
Highly effective treatments exist for anxiety disorders, mood
disorders, and sexual dysfunction Few treatments for alcoholism are
superior to the natural course of recovery that many people undergo
without psychological treatment People often resolve personal
problems on their own without psychological treatment Because
people tend to enter therapy when they experience crises, they
often show improvements no matter what therapy they receive
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Effectiveness of Treatment Is Determined by Empirical Evidence
The only way to know whether a treatment is valid is to conduct
empirical research that compares the treatment with a control
condition Randomized clinical trials can establish whether a
particular treatment is effective Findings from medical studies
often lead to dramatic changes in treatment practice Such
developments reflect the increasing importance of evidence-based
treatments
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Alzheimers Smell Test A simple scratch-and-sniff test could
flag the first signs of Alzheimers disease. As this ScienCentral
News video reports, the memory researcher whos developing the test
hopes to give doctors a jump on curtailing the devastation.
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Treatments That Focus on Behavior and on Cognition Are Superior
for Anxiety Disorders Treatment approaches to anxiety disorders
have had mixed success: Psychoanalytic theory did not prove useful
for treating anxiety disorders Evidence suggests that
cognitive-behavioral therapy works best to treat most adult anxiety
disorders (Hofmann & Smits, 2008) Anxiety-reducing drugs are
also beneficial in some cases Drug effects may be limited to the
period during which the drug is taken, whereas the effects of
cognitive-behavioral therapy persist long after treatment
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Specific Phobias Most phobias develop in the absence of any
particular precipitating event Learning theory cannot completely
explain the development of phobias; behavioral techniques are the
treatment of choice One method used is systematic desensitization
To expose clients without putting them in danger, practitioners may
use virtual environments Some cognitive strategies have also proven
useful for the treatment of phobia Brain-imaging data indicate that
successful treatment with cognitive-behavioral therapy alters the
way the brain processes the fear stimulus Pharmacological
treatments for phobias sometimes include tranquilizers, which can
help people handle immediate fears
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Panic Disorder Panic disorder has multiple components, and each
symptom may require a different treatment In the treatment of panic
attacks, cognitive-behavioral therapy appears to be as effective as
or more effective than medication (Schmidt & Keough, 2011)
Methods for treating panic disorder include: Cognitive
restructuring addresses ways of reacting to the symptoms of a panic
attack; helps clients recognize the irrationality of their fears
Breaking the connection between the trigger symptom and the
resulting panic through exposure treatment
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Obsessive-Compulsive Disorder Traditional anti-anxiety drugs
are completely ineffective for OCD The drug of choice for OCD is
clomipramine, a potent serotonin reuptake inhibitor (SSRI)
Cognitive-behavioral therapy is also effective for OCD The two most
important components of behavioral therapy for OCD are exposure and
response prevention There is evidence that adding CBT to SSRI
improves treatment outcomes; many practitioners recommend the
combination of these treatments (Franklin & Foa, 2011) Deep
brain stimulation (DBS) may be an effective treatment for those
with OCD who have not found relief from CBT or medication.
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Many Effective Treatments Are Available for Depression
Depression is one of the most widespread mental disorders among
adolescents and adults, and it has become more common over the past
few decades Scientific research has validated a number of effective
treatments, but there is no best way to treat depression Ongoing
research is being done to determine which type of therapy works
best for which types of individuals
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Pharmacological Treatment MAO inhibitors are effective but are
generally reserved for patients who do not respond to other
antidepressants Tricyclics are extremely effective antidepressants,
but they have a number of unpleasant side effects SSRIs are
prescribed most frequently because they have fewer serious side
effects than MAO inhibitors and tricyclics Physicians often must
resort to a trial-and-error approach in treating patients who are
experiencing depression as no single drug stands out as being most
effective
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Questions About Pharmacological Treatment Antidepressants may
help treat the symptoms of depression without having any influence
on the underlying cause Placebo treatments appear to be associated
with changes in neurochemistry and do alleviate symptoms for some
people Only drug trials that involve individuals with severe
depression show clear benefits of drugs over placebos, in part
because people with severe depression show less response to placebo
treatments (Kirsch et al., 2008) Both drugs and placebos help
people who are suffering from depression
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Cognitive-Behavioral Treatment Not all patients benefit from
antidepressant medications and some patients cannot or will not
tolerate the side effects Cognitive-behavioral therapy is just as
effective as antidepressants in treating depression (Hollon et al.,
2002) Cognitive-behavioral therapy can be effective on its own, but
combining it with antidepressant medication can be more effective
than either one of these approaches alone (McCullough, 2000)
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Alternative Treatments In patients with Seasonal Affective
Disorder ((SAD)/winter blues), episodes of depression are most
likely to occur during winter, with the rate of these disorders
increasing with latitude Many of these patients respond favorably
to phototherapy, which involves exposure to a high-intensity light
source for part of each day For some patients with depression,
regular aerobic exercise can reduce the symptoms and prevent
recurrence Electroconvulsive therapy (ECT) is a very effective
treatment for those who are severely depressed and do not respond
to conventional treatments Transcranial magnetic stimulation (TMS)
over the left frontal region results in a significant reduction in
depression
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Winter Mood The cold, dark days of winter are known to lower
the spirits of many people. Now scientists have a new therapy that
can make you feel like spring is in the air. This ScienCentral News
video has more.
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Deep Brain Stimulation DBS might be valuable for treating
severe depression when all other treatments have failed Several
studies have been done of using DBS for treatment-resistant
depression, and each time at least half of the clients benefited
from this treatment. Some of them felt relief as soon as the switch
was turned on
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Gender Issues in Treating Depression Women are twice as likely
to be diagnosed with depression as men The APA published Guidelines
for Psychological Practice with Girls and Women (2007) to build
awareness of gender-specific stressors Men are reluctant to admit
to depression and to seek appropriate therapy This has been
described as a conspiracy of silence that has long surrounded
depression in men (Brody, 1997) One goal is to help men stop
masking their depression with alcohol, isolation, and
irritability
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Undoing Depression You can train dogs to bark or sit. But what
about training mice to grow new brain cells? A Nobel Prize-winning
scientist has done that, and he says it could lead to new ways to
treat depression in people.
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Lithium Is Most Effective for Bipolar Disorder Bipolar disorder
is one of the few mental disorders for which there is a clear
optimal treatment: psychotropic medications, especially the mood
stabilizer lithium Lithium seems to modulate neurotransmitter
levels, balancing excitatory and inhibitory activities (Jope, 1999)
Lithium has unpleasant side effects including thirst, hand tremors,
excessive urination, and memory problems Lithium works better on
mania than on depression; patients often are treated with both
lithium and an antidepressant Patient compliance with drug therapy
can be a problem
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Pharmacological Treatments Are Superior for Schizophrenia
Historically, psychotic patients were often institutionalized in
large mental hospitals Brain surgery, such as prefrontal lobotomy,
was considered a viable option for patients with severe mental
disorders but was ineffective in treating people with schizophrenia
The introduction of psychotropic medications in the 1950s
eliminated the use of lobotomy
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Pharmacological Treatments Chlorpromazine and haloperidol
revolutionized the treatment of schizophrenia and became the most
frequently used treatments for this disorder Chlorpromazine: acts
as a major tranquilizer, reduces anxiety, sedates without inducing
sleep, decreases the severity and frequency of the positive
symptoms Haloperidol: is chemically different and has less of a
sedating effect than chlorpromazine These have little or no impact
on the negative symptoms of schizophrenia and have significant side
effects Second-generation antipsychotics such as Clozapine,
Risperdol, and Zyprexa are more effective and also have fewer side
effects
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Psychosocial Treatments Medication effectively reduces
delusions and hallucinations but does not substantially improve
patients social functioning Social skills training is an effective
way to address some deficits in patients When self-care skills are
deficient, behavioral interventions can focus on areas such as
grooming and bathing, management of medications, and financial
planning Initial studies using CBT for schizophrenia indicate that
it is more effective than other psychological treatments in
reducing symptoms such as delusions and hallucinations
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Prognosis In Schizophrenia It is in the best interest of
patients with schizophrenia to treat the disorder early and
aggressively Most patients with schizophrenia improve over time.
One long-term study that followed participants for an average of 32
years showed that between half and two-thirds were recovered or had
experienced considerable improvement in functioning on follow-up
(Harding, Zubin, & Strauss, 1987) The prognosis depends on
factors that include age of onset, gender, and culture
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15.3 Can Personality Disorders Be Treated? Discuss therapeutic
approaches for borderline personality disorder and antisocial
personality disorder.
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Can Personality Disorders Be Treated? Little is known about how
best to treat personality disorders as very few large, well-
controlled studies have been undertaken Most therapists agree that
personality disorders are notoriously difficult to treat Patients
see the environment rather than their own behavior as the cause of
their problems, which makes them very difficult to engage in
therapy
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Dialectical Behavior Therapy Is Most Successful for Borderline
Personality Disorder Marsha Linehans dialectical behavior therapy
(DBT) is the most successful in treating persons with borderline
personality disorder Combines elements of behavioral and cognitive
treatments with a mindfulness approach based on Eastern meditative
practices and proceeds in three stages: First, the patients most
extreme and dysfunctional behaviors are targeted with a focus on
replacing them with more appropriate ones Second, the therapist
helps the patient explore past traumatic experiences that may be at
the root of emotional problems Third, the therapist helps the
patient develop self-respect and independent problem solving
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Antisocial Personality Disorder Is Extremely Difficult to Treat
Treating those with antisocial personality disorder often seems
impossible Patients lie without thinking twice about it, care
little for other peoples feelings, and live for the present without
consideration of the future Patients are often more interested in
manipulating therapists than in changing their own behavior, which
means therapists must be constantly on guard
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Therapeutic Approaches for Antisocial Personality Disorder
Psychotropic medications have not been effective in treating this
disorder Traditional psychotherapeutic approaches are of little
use, whereas behavioral and cognitive approaches have had somewhat
more success Therapy for this disorder is most effective in a
residential treatment center or a correctional facility
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Prognosis for Antisocial Personality Disorder The prognosis
that patients with antisocial personality disorder will change
their behaviors as a result of therapy is poor, particularly for
patients with psychopathic traits Fortunately for society,
individuals with antisocial personality disorder but without
psychopathy typically improve after age 40 Conduct disorder is a
childhood condition known to be a precursor to antisocial
personality disorder Time and effort may be better spent in
prevention than in treatment
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15.4 How Should Childhood Disorders and Adolescent Disorders Be
Treated? Discuss the current controversy regarding the use of drugs
to treat depression among adolescents Identify drugs and behavioral
treatments for ADHD Describe applied behavioral analysis Discuss
the use of oxytocin in the treatment of autism
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How Should Childhood Disorders and Adolescent Disorders Be
Treated? In the United States, an estimated 12 percent to 20
percent of children and adolescents suffer from mental disorders
Problems not addressed during childhood or adolescence may persist
into adulthood Children and adolescents are more malleable than
adults and more amenable to treatment Childhood and adolescent
disorders should be the focus of research into etiology,
prevention, and treatment
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The Use of Medication to Treat Adolescent Depression Is
Controversial Approximately 8 percent of the U.S. population, ages
12 to 17, reported experiencing within the last year a major
depressive episode that met DSM criteria (SAMHSA, 2011) About
one-third of adolescents with psychological disorders receive any
form of treatment; the percentage is even lower for adolescents
from racial and ethnic minorities SSRIs are effective, but increase
the risk of suicidal thinking and suicidal behavior in children and
adolescents
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TADS Treatment for Adolescents with Depression Study (TADS,
2004) provided clear evidence that the SSRI Prozac is effective in
treating adolescent depression The group receiving Prozac and CBT
did best (71 percent improved) Participants in the Prozac group
were twice as likely to have serious suicidal thoughts or
intentions compared with those undergoing other treatments Overall,
suicide attempts were quite uncommon (7 of 439 patients)
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Further Thoughts On Treatment Approaches The main question is:
Do the millions of children who take antidepressants experience
more benefits than risks? Suicide rates have dropped since the use
of SSRIs became widespread Not providing SSRIs to adolescents may
raise the suicide rate (Brent, 2004) CBT is most effective but
expensive and time-consuming Prescribing drugs without CBT might be
cost-effective (Domino et al., 2008), but it may not be in the best
interests of adolescents with depression
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Children With ADHD Can Benefit from Various Approaches There is
some dispute about whether attention deficit hyperactivity disorder
is a mental disorder Some people diagnosed with ADHD as children
grow out of it Many suffer from the disorder throughout adolescence
and are more likely to drop out of school; to reach a lower
socioeconomic level than expected; show continued patterns of
inattention, of impulsivity, and of hyperactivity; and they are at
increased risk for other psychiatric disorders (Wilens, Faraone,
& Biederman, 2004) Effective treatment early in life may be of
great importance
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Pharmacological Treatment of ADHD The most common treatment for
ADHD is a central nervous system stimulant, such as methylphenidate
(Ritalin) Functional brain imaging shows that children with ADHD
have underactive brains; their hyperactivity may raise their
arousal levels Studies have shown that children taking Ritalin are
happier, more adept socially, and somewhat more successful
academically, although the effects on academic performance are
modest The medication has its drawbacks: Side effects include sleep
problems, reduced appetite, body twitches, and the temporary
suppression of growth Most therapists believe medication should be
supplemented by psychological therapies, such as behavior
modification
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Behavioral Treatment of ADHD Behavioral treatment of ADHD aims
to reinforce positive behaviors and ignore or punish problem
behaviors A recent meta-analysis of 174 studies consisting of over
2,000 research participants found clear support for the
effectiveness of behavioral therapy for ADHD (Fabiano et al., 2009)
Many therapists advocate combining behavioral approaches with
medication Studies show that medications may be important in the
short term, but psychological treatments may produce superior
outcomes that last
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Children With Autism Benefit from Structured Behavioral
Treatment Core symptoms of autismimpaired communication, restricted
interests, and deficits in social interaction make these children
particularly difficult to work with Normal children respond
positively to social praise and small prizes, but children with
autism often are oblivious to these rewards; food is sometimes the
only effective reinforcement in the initial stages of treatment
Structured therapies are more effective for these children than are
unstructured interventions, such as play therapy
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Behavioral Treatment For Autism One of the best-known and
perhaps most effective treatments for children with autism is
applied behavioral analysis (ABA) ABA is based on principles of
operant conditioning: This very intensive approach requires a
minimum of 40 hours of treatment per week Initiating treatment at a
younger age yielded better results, as does involving parents
Research example: Instruction in symbolic play also leads to
increased language use, greater parent/child play, and greater
creativity in play
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Biological Treatment For Autism SSRIs are not helpful for
treating the symptoms of autism and actually may increase agitation
(McPheeters et al., 2011) Antipsychotics, such as Risperdal, appear
to reduce repetitive behaviors associated with self-stimulation but
have side effects (e.g., weight gain) A deficit in oxytocin may be
related to some of the behavioral manifestations of autism; studies
show that it may improve functioning in people with autism
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Prognosis For Children With Autism The long-term prognosis for
people with autism is poor Early diagnosis clearly allows for more
effective treatments (National Research Council, 2001) A higher IQ
may mean a better ability to generalize learning and therefore a
better overall prognosis Severe cases are less likely to improve
with treatment
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A Case Study of Childhood Autism John ONeil, a deputy editor at
the New York Times, described what it is like to be the parent of a
child with autism (ONeil, 2004) Many children who will develop
autism show abnormal social behavior in infancy Most diagnoses of
autism are made by age 3, but the disorder can be detected earlier
if parents or pediatricians know what to look for Signs include
staring at objects for long periods, not reaching developmental
milestones, withdrawal from social contact, stopping babbling,
self-abuse The earlier diagnosis and treatment begins, the better
the prognosis Luckily for ONeils son James, preschool staff
recommended a professional evaluation because of his unusual
behavior and he received treatment
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Autism and Virtual Pals Kids with autism have trouble listening
and responding, but they may get some help from a virtual friend.
As this ScienCentral News video explains, technology could help
isolated kids make connections in the real world.