Children with Emotional and Behavioral Disorders

Marianne Celano

• Publisher: Momentum Press
• Year: 2018
• ISBN:
  9781945612992
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

This concise book is for students and therapists who wish to develop competencies in family therapy and systemic practice with children. Using a fictional clinical case, the book describes the contributions of couple and family psychology (CFP) to the understanding and treatment of emotional and behavioral disorders among children ages 2 to 12. CFP competencies are presented and applied to the case of a nine-year-old girl with school refusal and behavior problems. The book describes how a systemic perspective affects clinical decisions from intake to treatment termination. Specific competencies discussed include: scientific knowledge, assessment, evidence-based practice, intervention, individual and cultural diversity, ethical and legal standards, and reflective practice. Readers will come away from this book with a clear sense of how to conceptualize and treat common childhood emotional and behavioral disorders from a systemic perspective.

CHAPTER 1

Introduction to Family Psychology: The Medina Family

Learning how to do psychotherapy with children and their families is a complex process that takes time, supervised experience, and mastery of a broad base of knowledge, skills, and attitudes. The application of a systemic perspective to this work adds even more complexity, but also yields greater returns, as it addresses the multiple contexts in which children’s development is embedded. What is a systemic perspective, and how does it affect clinical decisions at a family’s entry into services? These questions are best answered in part through case illustration. The following sections introduce a family that is the focus of this book, describe how a systemic perspective guides early clinical decisions, and discusses the goals of the book.

A Family in Crisis

Emilio and Karen Medina were referred to the clinic by their pediatrician, Dr. Shin, for evaluation of their nine-year-old daughter, Elena. Presenting problems include irritability, stomach aches, difficulty sleeping, nightmares, poor concentration, impulsivity, tantrums, and refusal to attend school consistently. The parents report that Elena has always been a “difficult child,” but her tantrums have grown more severe and frequent over the last year, and in recent weeks, she has refused to go to school three to four days per week, complaining of stomach aches. Dr. Shin has evaluated and treated Elena’s stomach pain, and will not provide any more medical excuses for her absences.

The Medina family consists of Emilio, age 45; Karen, age 39; Elena, age nine; and Julian, age six. Emilio is a software engineer who works full time; Karen is a nurse who works part time. Julian (1st grade) and Elena (4th grade) attend the same public elementary school. The family lives in a suburb of Atlanta.

This is the information available on an intake form in an outpatient clinic. In many behavioral health (BH) organizations, the referred child and a parent will participate in a diagnostic evaluation or intake session before treatment decisions and recommendations are made. However, BH providers often make case assignments based on only limited information, such as the preceding brief case description. For example, should the case be assigned to a clinician who does individual child therapy or family therapy? Should it be given to a trainee or a seasoned BH clinician (henceforth called “clinician”)? If the organization has specialty clinics, should the family be evaluated in the anxiety disorders clinic or the behavior disorders clinic?

The Role of Theory in Clinical Decisions

It is at this early juncture that the practitioner’s theoretical orientation influences clinical decision-making. For a clinician assigned Elena Medina, theory guides which questions are asked, how the presenting problem is explained, and which interventions are recommended. A clinician with strong grounding in attachment theory would inquire about Elena’s earliest years of life, the history and quality of her relationships with her primary caregivers, and any threats to the stability and continuity of these relationships. A clinician with a cognitive behavioral theoretical orientation would explore the antecedents and contingencies for Elena’s symptoms and challenging behaviors, and ultimately recommend individual cognitive behavioral therapy (CBT). A clinician well-versed in psychodynamic approaches might recommend play therapy.

By contrast, a clinician with a family systems orientation conceptualizes the problems of children as embedded within a matrix of reciprocal interaction between intrapersonal, interpersonal, and environmental factors. A systems framework is not inconsistent with attachment-based, cognitive behavioral, or psychodynamic formulations of disordered child behavior. A systems perspective may be inclusive of some or all of these formulations, but embeds them within a larger framework that includes the relationships within the family (nuclear and extended), and the child’s and family’s relationships in the community (e.g., parents’ employer and friends, child’s peers and school, religious organizations, systems of care). Application of a family systems orientation to clinical work does not necessarily result in a recommendation for family therapy.

Application of a Systemic Perspective to the Case

Application of a systemic paradigm to the Medina case generates a number of questions:

1. How do the parents understand Elena’s problems? How do others in the family understand it? Do the parents view the problem similarly or differently?

2. From whom do the parents obtain emotional and instrumental support in childrearing?

3. From which doctors, school personnel, and others in the community have the parents sought help for Elena’s problems? How do family members describe their help-seeking experience?

4. How do Elena’s problems affect her parents, their relationship with one another and with Elena, and the parents’ relationships with others?

5. How do Elena’s problems affect her younger brother, her relationship with him, or her parents’ relationship with him?

6. What is the function, if any, of Elena’s behavior problems?

The clinician can ask the parent(s) one or more of these questions in a telephone conversation prior to making a decision about case assignment or a recommendation about who should attend the first assessment session. One advantage of asking these questions is that they allow the parents to share their thoughts and concerns, to receive validation and support, and to begin to develop a measure of trust in the clinician. A second advantage is that these questions communicate an expectation of collaboration between clinician and family in solving the presenting problems. Third, parents who have explored these questions are likely to bring to the assessment session family members in addition to the referred child, if they are invited to do so. Finally, the clinician obtains important information to guide assessment decisions.

For the Medina family, these questions yielded the following information, obtained by the intake clinician during a 20-minute phone call with the mother:

Karen believes that Elena tries to be perfect, and is too competitive in school and sports. She thinks her daughter is refusing school because she has recently experienced some verbal bullying from other 4th grade girls. Karen is frustrated with how clingy and demanding her daughter has become, and she worries that Julian, a comparatively easy and cheerful child, will start acting like his sister. She reports that Emilio is “harder” on Elena than she is, but also loses his temper with her more easily. He reportedly views Elena’s behavior as manipulative and attention-seeking, and the parents often disagree about the best way to discipline her.

The parents are too embarrassed to discuss Elena’s behavior problems with their friends. There are no extended family members in Atlanta. Emilio’s parents and sisters live in south Florida; Karen’s family members are more dispersed and live in the Northeast and the Midwest. Emilio is reportedly close with his parents and talks with his mother often. The paternal grandmother is also concerned about Elena’s behavior, and has offered several suggestions, none of which has worked. Karen does not talk with her parents or siblings about Elena’s behavior problems.

Karen and Emilio have discussed Elena’s behavior problems with her teacher and school counselor. Both report that Elena is an excellent student and gets along well with peers. They have expressed concern about how many days Elena has missed school and have suggested that the parents consider a home-bound academic program if she cannot attend school regularly. Karen asked the pediatrician, Dr. Shin, to sign the form for home-bound instruction, but the doctor declined, referring the family to BH services for Elena instead.

The role of the clinician from this point forward will depend on the referral question, the developing hypotheses about the case, and the clinician’s responsibilities in the BH clinic. Depending on the setting and the clinician’s competencies, these responsibilities may include BH screening, consultation, referral, diagnostic evaluation, psychological testing, medication evaluation, and psychotherapy (individual, group or multi-group, couples, family). The referral questions for the Medina family may include: (a) to what extent do Elena’s presenting problems reflect psychiatric problems that can be addressed by BH services?, (b) what is Elena’s psychiatric diagnosis?, (c) to what extent are family and community processes contributing to Elena’s presenting problems?, and (d) what BH intervention(s) are recommended?

A Family Psychology Framework for Child Problems

Child Behavioral and Emotional Problems

Emotional and behavioral disorders are common among children. Approximately 13 to 20 percent of the children in the United States experience these disorders (Perou et al., 2013); globally, one in four children and adolescents experience a psychiatric disorder in a given year (Merikangas, Nakamura, & Kessler, 2009). In the United States, the rates of clinically significant behavioral and emotional difficulties are even higher for children from economically disadvantaged families (Webster-Stratton & Hammond, 1998) and higher still (50 percent) for children in foster care (Burns et al., 2004). The most commonly diagnosed childhood psychiatric disorder is attention-deficit/hyperactivity disorder (ADHD), affecting 8.5 percent of the children 8 to 15 years old (Merikangas et al., 2009). Anxiety disorders also are prevalent, occurring in 6 to 9 percent of children under age 13 (Beesdo, Knappe, & Pine, 2009). In addition, disruptive behavior disorders are common; the prevalence of oppositional defiant disorder (ODD) is approximately 3.3 percent (American Psychiatric Association, 2013). However, prevalence estimates of psychiatric disorders underestimate the number of children with significant clinical impairments (Brotman et al., 2006).

Couple and Family Psychology

Family psychology, or couple and family psychology (CFP) as it is known by the American Board of Professional Psychology (ABPP), is a specialty in professional psychology that utilizes a systemic epistemology to assess and treat issues of psychological health and pathology among individuals, couples, families, and larger social systems. CFP specialists conceptualize behavior within a theoretical framework that recognizes the reciprocal interaction among individual (biological and psychological variables), interpersonal, and contextual factors over time. Children’s emotional and behavioral problems are seen as embedded within transactional processes occurring within and across the levels of the individual child, the family, and other environmental contexts, including the school, peer group, health-care teams, and systems of care. Individual factors (e.g., identities, beliefs) and interpersonal interaction patterns are nested within and influenced by broader contextual variables (e.g., culture, age, religion), and one or more of these variables (e.g., gender) may influence others (e.g., race).

This systemic epistemology is often different from theories about psychopathology typically taught in psychology and psychiatry training settings. For example, psychologists and psychiatrists usually learn how to apply a biopsychosocial case formulation, which requires identification and integration of etiological influences from biological, psychological, and social domains. A biopsychosocial formulation of the Medina case would consider the potential causal mechanisms of Elena’s difficulties with executive functioning (e.g., impulsivity, poor concentration) and physiological reactivity, her negative thoughts about school, the perceived bullying from peers, and the parents’ inconsistent (and incompatible) reactions to her difficult behavior.

A systemic case conceptualization is more than a biopsychosocial formulation. A CFP specialist would consider the same biopsychosocial etiological factors, but would also attend to: (a) how they interact with one another over time, and (b) the historical and sociocultural context of childrearing for the family. A systemic formulation would explore not just the impact on Elena of the parents’ disagreements regarding discipline, but also the impact of Elena’s symptoms and negative behavior on the parents’ individual functioning, parent-child relationship, and marital relationship, which in turn may contribute to the severity, frequency, or duration of the presenting problems. In addition, the CFP specialist would explore how broader sociocultural factors (e.g., cultural values related to childrearing) and historical factors (e.g., parents’ experiences in their families of origin) contribute to more proximal etiological factors, such as parenting behavior and the conflicting parental reactions to Elena’s challenging behavior.

CFP Approach to Treatment of Children

A CFP approach to treatment of children’s emotional and behavioral disorders can be justified on theoretical, empirical, and ethical grounds. The potential impact of the environment on child psychopathology has been recognized since 1920, when John B. Watson used classical conditioning to create fear in a young child (Watson & Rayner, 1920). Current developmental m...

Table of contents

• Cover
• Half-title Page
• Title
• Copyright
• Abstract
• Contents
• Chapter 1 Introduction to Family Psychology: The Medina Family
• Chapter 2 The Science Supporting a Family Systems Approach
• Chapter 3 Family Assessment and Systemic Case Conceptualization
• Chapter 4 Evidence-Based Practice and Treatment Planning
• Chapter 5 Systemic Interventions
• Chapter 6 Foundational Competencies and Termination
• About the Author
• Index
• Adpage
• Backcover