STUDY NOTES: CHAPTER 17 - CLINICAL CHILD AND ADOLESCENT

PSYCHOLOGY
Clinical psychologists have worked with children and adolescents since the inception of the field. The first
psychology clinic by Lightner Witmer focused on learning and behavioral problems in children.

Clinical child psychologists work in assessment, therapy, research, and training, applying professional skills in
diverse ways.

Clinical Child and Adolescent Psychology

 Clinical psychologists have worked with children and adolescents since the inception of the field.
 The first psychology clinic, created by Lightner Witmer in the late 1800s, focused on assessment and
treatment of children with learning and behavioral problems.
 Clinical child psychology has grown tremendously (Carr, 2016; Lochman, Boxmeyer, & Powell, 2016).
 The Society of Clinical Child and Adolescent Psychology (Division 53 of the APA) has thousands of
members.
 Many graduate programs specifically train psychologists to work with children and adolescents.

Roles of Clinical Child Psychologists

 Specialize in the assessment of behavioral, emotional, or intellectual problems.

 Work as therapists with children and families.
 Engage in research or training.
 Combine applied and academic roles.
 Involved in pediatric psychology, promoting mental and physical health for children with medical
conditions.

Major Areas in Clinical Child Psychology

 Psychological problems of children

 Assessment.
 Psychotherapy.

PSYCHOLOGICAL ISSUES OF CHILDHOOD

Disorders of Childhood

Common disorders:

 Attention-deficit/hyperactivity disorder (ADHD)

 Conduct disorder
 Oppositional defiant disorder
 Separation anxiety disorder
Children and adolescents can also be diagnosed with disorders common to adults:

 Major depression
 Posttraumatic stress disorder
 Eating disorders (anorexia, bulimia)
 Substance use disorders
 Phobias
 Generalized anxiety disorder

DSM-5 Adjustments for Children:

 Irritable mood can replace depressed mood in major depressive episodes.

 Failure to gain expected weight can replace weight loss.
 Fear and anxiety may appear as crying, tantrums, or clinging.
 PTSD has distinct criteria for children 6 years and younger, including diminished interest in
playing or trauma reenactment.

Externalizing vs. Internalizing Disorders

 Externalizing: "acting out," disruptive behavior. Disruption to parents, teachers, or other

children (e.g., ADHD, conduct disorder).
 Internalizing: maladaptive thoughts/feelings. Less noticeable than externalizing disorders (e.g.,
depression, anxiety).

Resilience and Vulnerability

 Essential question for clinical child psychologists: Why do some children develop psychological disorders,
whereas others do not?
 Children from similar environments (same area, ethnicity, socioeconomic level, school, family) can have
very different psychological or behavioral problems.

Risk Factors Contributing to Vulnerability

 Environmental Factors:

 Poverty
 Serious emotional conflict among parents
 Single parenthood
 Excessive number of children in the home
 Neighborhood or community factors
 Poor schooling

 Parental Factors:

 Poor parental physical health

 Poor parental mental health
 Low parental intelligence quotient (IQ)
 Hypercritical tendencies in parents
 Child (Internal) Factors:

 Medical problems
 Difficult temperament
 Low IQ
 Poor academic achievement
 Social skills deficits

 Role of Family in Vulnerability

 More psychological problems in parents increase likelihood of psychological problems in children.

 Study findings:

 Children whose parents had a mental illness at age 3 were more likely to be diagnosed with
mental illness by ages 4, 5, or 6.
 Parental diagnoses linked to increased child risk: ADHD, depression, anxiety disorders,
personality disorders.
 Nonanxious parents contribute to better anxiety disorder outcomes in children after treatment.

 Role of Sibling Relationships

 Warm, loving sibling relationships are linked to fewer internalizing and externalizing disorders.
 Conflictual sibling relationships are linked to higher likelihood of both types of disorders.

 Factors Contributing to Resilience

External Supports ("I Have")

 Trustworthy family members

 Good role models
 Access to external resources

Inner Strengths ("I Am")

 Personal traits such as responsibility, confidence, and self-respect

Interpersonal and Problem-Solving Skills ("I Can")

 Skills to solve problems and express emotions appropriately

 Clinical child psychologists can design interventions to enhance these resilience factors.

 Implicit Theories and Mental Health

Fixed (Entity) Theory:

 Belief that personal traits are unchangeable (e.g., "I am shy and there’s nothing I can do about
it").
 Associated with higher risk of mental health problems.

Malleable (Incremental) Theory:

  Belief that personal traits can change and improve (e.g., "I am shy but can overcome it").
 Associated with lower risk of mental health problems.
 Meta-analysis of 17 studies:

 Kids aged 4–19 who believed in fixed traits had more frequent and severe psychological
diagnoses (both internalizing and externalizing) compared to those who believed traits were
malleable.

ASSESSMENT OF CHILDREN AND ADOLESCENTS

The Developmental Perspective

 In any competent assessment of a child or adolescent, clinical psychologists adopt a developmental

perspective.
 Essential to understand the child’s behavior within the context of the child’s developmental stage.
 Problems may have different meanings and require different interventions depending on age.
  Example: Defiant, rule-breaking behavior by Beth interpreted differently if she is 7 vs. 17.
 Example: Bed-wetting in Donyell interpreted differently at age 3, 9, or 15.

 Ethnicity and diversity-related factors can influence developmental maturation.

 Cultural groups may expect children to develop quickly or slowly in specific areas.
 Example: "Parentified" child role common in African American families may enhance
responsibility but cause later behavioral issues.

A Comprehensive Assessment

 Extensive background information is essential.

 Helps understand the circumstances surrounding the child’s presenting problems.

Key Background Questions:

 Presenting Problem:

 What exactly is the presenting problem?

 Do parents, child, teachers agree on the definition?
 When did it arise? For whom is it most troubling?

 Development:

 Current physical, cognitive, linguistic, social development.

 Any developmental abnormalities during childhood or prenatal period.
 Reaching developmental milestones on time.

 Parents/Family:

 Characteristics of the parents.

 Parenting style used.
 Parent psychological, medical factors.
 Influence of siblings, grandparents, other family members.

 Environment:

 Larger environment outside family.

 Relevant ethnic or cultural factors.
 Recent major life events.

Multisource, Multimethod, Multisetting Approach (Merrell, 2008)

 Multisource Assessment:

 Sources: parents, relatives, teachers, school personnel, child.

 Important to avoid relying on only one source.
 Disagreements common, especially in internalizing disorders.
  Multimethod Assessment:

 Different data collection methods: interviews, questionnaires, direct observation.

 Multisetting Assessment:

 Data from multiple settings: home, school, clinician's office, others.

Example: Ari's Case Study

 7-year-old boy described by parents as "impossible to manage."

 Parents reported unruly behavior at home.
 Teacher and babysitter described Ari as compliant and well-behaved.
 Direct school observation confirmed good behavior.
 Conclusion: Problem was situational to home setting.
 Intervention: Improve parents' communication and management strategies at home, leading to
successful results.

Assessment Methods

 Six broad categories: clinical interviews, behavioral observation, behavior rating scales, self-report scales,
projective/expressive techniques, and intellectual tests.

 Interviews

 Unlike adult assessments, clinical child psychologists interview the child and other informants
(parents, teachers, siblings, grandparents, pediatricians, coaches, etc.).
 Empathize with parents, correct misconceptions, collaborate constructively.
 Permission needed before contacting individuals other than parents.
 Contacting teachers professionally and at appropriate times is important.
 Interviewing children requires establishing rapport, adjusting speech patterns, and showing
genuine respect.
 Structured and unstructured interviews are commonly used.

 Behavioral Observations

 Used for observable behaviors, often externalizing disorders.

 Observation in real settings: home, school.
 Systems: Direct Observation Form, Student Observation System, Dyadic Parent-Child
Interaction Coding System, Social Interaction Scoring System.
 Event-based systems: count behavior occurrences.
 Interval-based systems: note behavior occurrence per time segment.
 Concerns: Reactivity (children change behavior because of observer).
 Cultural awareness during observation is critical.
 Analogue direct observation: simulate real-life situations in clinical settings.

 Behavior Rating Scales

 Standardized forms completed by parents, teachers, or adults.

  List of behaviors rated on frequency scales.
 Common tools: Child Behavior Checklist (CBCL), Behavior Assessment System for Children,
Conners’ Rating Scale (attention), Children’s Depression Inventory (depression).
 Advantages: convenient, inexpensive, objective.
 Disadvantages: restrict elaboration, may not capture all behaviors.

 Self-Report Scales

 Completed by children or adolescents, assuming appropriate reading level, attention, and

motivation.
 More common with adolescents.
 Examples: MMPI-Adolescent, PAI-Adolescent, MCMI-Adolescent.
 Focused tools for specific symptoms: depression, anxiety.
 Cultural competence required: language fluency and appropriate normative data.

 Projective/Expressive Techniques

 Include Rorschach Inkblot Method, Thematic Apperception Test (TAT), sentence-completion

tasks.
 Children-specific tools:

 Children’s Apperception Test (animal characters).

 Roberts Apperception Test (ethnically diverse characters).
 Tell-Me-a-Story (TEMAS): culturally sensitive, theme-focused cards for storytelling.

 Expressive techniques:

 Draw-a-Person Test.
 Kinetic Family Drawing.
 House-Tree-Person Test.

 Drawings interpreted cautiously, considering cultural influences (e.g., Japanese anime styles).

 Intellectual Tests

 IQ tests and achievement tests assess intellectual functioning.

 Full psychological evaluations often include intellectual tests.
 Specific evaluations (e.g., learning disorder) may focus mainly on these.
 Spanish WISC-IV: improved version for Spanish-speaking children.
 Cultural fairness considerations: Universal Nonverbal Intelligence Test (UNIT).
 Translation vs. culture-specific content importance.

Frequency of Use of Specific Assessment Techniques

 A 2002 survey (Cashel, 2002) measured how often specific tests were used during child and
adolescent assessments.
 Survey respondents: American Psychological Association members from Division 53 (Clinical
Child Psychology) and other child-focused divisions.
Key Findings:

 Interviews:

 Used far more commonly than any specific assessment technique.

 Noninterview Techniques:

 Different sets of instruments for adolescents versus younger children.

 Greater reliance on self-report measures for adolescents.
 Greater reliance on behavior rating scales (completed by parents or teachers) for younger
children.

 Test Usage:

 Some tests (e.g., WISC) are relatively common.

 Significant variation remains among clinicians.

Recent Findings:

Although the 2002 survey is dated, more recent studies suggest its findings remain largely valid.

 2014 Survey (Ready & Veague, 2014):

 WISC, Child Behavior Checklist (ASEBA), and WIAT were among the top child-focused
tests taught in clinical psychology graduate programs.

 2017 Survey (Wright et al., 2017):

 WISC and Child Behavior Checklist (ASEBA) were among the top child-focused tests used
by practicing psychologists conducting assessments.
 PSYCHOTHERAPY WITH CHILDREN AND ADOLESCENTS

 Therapy with children and adolescents may look different from therapy with adults, but techniques often
originate from the same theories (psychodynamic, humanistic, behavioral, cognitive).
 Children should not be mistaken for miniature adults; therapy requires substantial adjustments.

 Differences from Adult Therapy

 Adult therapy assumptions:

 Willingness to be in therapy.
 Motivation to change.
 Ability to sit calmly and express feelings verbally.

 With children and adolescents:

 These assumptions cannot be taken for granted.

 Children usually don't come to therapy alone; parents, relatives, and teachers are often
involved.
  Therapeutic alliance must include the child and the parent(s), not just the client.

 Therapeutic Alliance

 Crucial for therapy outcomes with children and adolescents.

 Must involve multiple parties: child and parent(s).

 Therapy Methods

 Over 551 distinct psychotherapy techniques for children and adolescents (Kazdin, 2000).
 Focus is on sampling active forms of child therapy practiced today.

Cultural Competence

 Essential with any form of therapy.

 Must consider cultural variables: race, ethnicity, gender, sexual orientation, socioeconomic status,
religion.
 Childhood and adolescence can be considered their own "culture" with unique beliefs, customs,
and technology use.

Youth Culture and Social Media

 Awareness of youth culture and social media use is important.

 Study findings (Pagnotta et al., 2018):
 Adolescents' perception of therapists' social media competency strongly correlates with therapeutic
alliance.
 Key therapist behaviors valued by teens:

 Valuing and respecting social media use.

 Comfort with diverse social media habits.
 Demonstrating knowledge about social media platforms.
 Understanding problems within the context of social media habits.

 Higher ratings on these items predict stronger therapeutic alliance, which is a key predictor of
therapy outcomes.

Cognitive-Behavioral Therapies (CBT) for Children

 Cognitive-behavioral therapies (CBT) for children are on the rise.

 Represent movement toward evidence-based treatment and reliance on empirical data.
 Therapies involve behavioral techniques, cognitive techniques, or a combination of both.

Evidence for CBT

 Empirical evidence from manual-based psychotherapy outcome studies.

 Beneficial for various disorders: depression, ADHD.
 Most strongly supported for anxiety disorders:

 Obsessive-compulsive disorder (OCD)

  Panic disorder
 Phobias (school phobia/school refusal)
 Social phobia

Treatment Principles

Principles are similar to adult treatments but delivery methods differ.

Phobia Treatment:

 Gradual exposure to feared object/situation.

 Often combined with relaxation training.

OCD Treatment:

Exposure with response prevention.

Anxiety Treatment:

 Cognitive restructuring to challenge illogical thoughts.

Adaptations for Children

Interventions adapted into games:

 Bravery Bingo: Token earned for each successful exposure.

 Mr. OCD: Kids practice cognitive restructuring by refuting flawed logic expressed by a
puppet.

Homework assignments reinforced with stickers, candy, privileges, or praise.

Specific Behavioral Treatments

Social Skills Training:

 Teaches behaviors improving interaction with others.

 Used for autism spectrum disorder, social anxiety disorder, ADHD.
 Skills targeted:

Starting conversations

Joining ongoing interactions

Expressing feelings appropriately

Handling frustration

Managing eye contact, nonverbals, and voice tone/volume

 Skills are modeled, rehearsed, and reinforced with meaningful rewards.

 Applied Behavior Analysis (ABA):

 Based on operant conditioning principles: reinforcement, punishment, shaping, extinction.

 Evidence-based therapy, especially for autism spectrum disorder.
 Therapist identifies and defines specific target behaviors.

Goals:

Increase positive behaviors (e.g., eye contact, self-dressing, independent toileting).

Decrease negative behaviors (e.g., self-injury).

 Baseline and frequency goals set.

 Functional analysis performed to understand behavior contingencies.
 Behavior modified through contingency management (rewards/punishments).
 Emphasis on generalizing behavior changes to new environments.

Self-Instructional Training

 Developed by Donald Meichenbaum (1977, 1985, 2008).

 Originally for impulsive and disruptive children, expanded to various childhood and adult problems.
 Also called "guided self-dialogue."

Key Concepts

 Form of cognitive therapy where children "talk through" situations.

 Goal: Increase likelihood of using preferred behavior.

Training Process

 Target behavior/situation identified.

 Therapist models behavior while talking out loud.
 Child tries behavior with therapist's verbal guidance.
 Child says instructions aloud during behavior.
 Child whispers instructions.
 Child eventually completes behavior silently using internal self-instructions.
 Mirrors natural developmental internalization of instructions.

Purpose

 Nurture a problem-solving attitude.

 Introduce specific cognitive strategies (self-statements).
 Replace negative or absent self-statements with constructive ones.
 Use self-statements during:

 Preparation for stressor.

 During the stressful moment.
 Reflection after the stressor.
Example: Nicholas, 7-year-old Hyperactive Student

 Problem: Disruptive during classroom transitions.

 Training Steps:

 Therapist models transition behavior out loud.

 Nicholas practices behavior while being verbally guided.
 Nicholas gradually internalizes self-instructions.

 Outcome: Nicholas successfully uses self-instruction to manage transitions.

Broader Applications in CBT for Kids

Problem-Solving Strategies:

 Predefined step-by-step sequences.

 Example: Keeping Your Cool program (SPEAR acronym):

 S: Stop (identify the problem)

 P: Plan (consider solutions)
 E: Evaluate (choose a solution)
 A: Act (try the solution)
 R: React (assess if it worked)

Affective Education:

 Emphasis on recognition, differentiation, and expression of emotions.

 Helps kids understand and normalize their feelings.
 Example: Coping Cat program:

 Kids create their own feelings dictionary.

 Recognize emotions in others' facial expressions.

Parent Training

 Parent training: Behavioral therapy where therapists teach parents conditioning techniques to modify
children's problematic behaviors.
 Parents act as the primary agents of change by managing the child's environment.

Key Concepts

 Begins with a clear, measurable definition of the child's problem behavior.

 Therapist and parents conduct a functional analysis to understand behavior contingencies.
 Explore and implement appropriate consequences.
 Therapist models desired behaviors for parents.
 Parents apply new contingencies at home and report outcomes with objective, quantifiable measures.

Behavioral Concepts Discussed:

  Reinforcement
 Punishment
 Extinction
 Generalization
 Discrimination
 Schedules of reinforcement (fixed or variable)

Applications

 Used for problems such as:

 ADHD
 Conduct disorder
 Separation anxiety
 School refusal
 Sleep/wake problems

 Examples of large-scale programs:

 Triple P–Positive Parenting Program

 Incredible Years training series

Outcomes

 Improved behavior in the child.

 Increased competence and confidence in parents.

Example: Patty and Miranda

Problem: Miranda (3 years old) assaults her sister Joy (6 years old) daily.

Initial Response: Patty responds with kind talks, hugs, and kisses after aggression—inadvertently
reinforcing Miranda's behavior.

New Contingency Plan by Dr. Fisk:

 Full day without aggression = 5-minute bedtime snuggle.

 Aggressive behavior = Immediate 3-minute timeout.
 Disobeying timeout = Loss of dessert and TV privileges.

Additional Teaching:

 Concept of "extinction burst" explained to Patty (behavior might intensify before extinguishing).

Outcome:

 Patty consistently applied the new contingency.

 Miranda's aggressive behavior greatly reduced.
Play Therapy

 Unique treatment form for child clients, typically younger (preschool or elementary school age).
 Allows communication via play (dollhouses, action figures, toy animals) rather than words.

 Functions of play therapy (Brems, 2008):

 Formation of therapeutic relationships.

 Disclosure of feelings and thoughts.
 Healing (coping skills, new behaviors).

 Can be unstructured or structured.

Cultural Sensitivity in Play Therapy

 Toys and materials should reflect children's cultural backgrounds.

 Examples:

 Dolls with various African American features (Hinds, 2005).

 Traditional Mexican toys like Juego de la Oca and Serpientes y Escaleras (Robles, 2006).
 Multicultural crayons and kitchen items (Drewes, 2005a).

 Awareness of cultural norms like personal space, eye contact, and silence is crucial (Drewes, 2005b).

Effectiveness

 Meta-analyses suggest play therapy is generally effective.

 Challenges:

Lack of therapy manuals.

Lack of diagnosis-specific focus.

Lack of reliable outcome measures.

 Difficulty achieving evidence-based status.

Types of Play Therapy

Psychodynamic Play Therapy

 Symbolic play communicates unconscious processes.

 Therapist acts as participant and observer.
 Goal: Make unconscious conscious.
 Use of a variety of objects; attention to chosen toys and play themes.
 Example: Cassandra's play revealed feelings of responsibility and powerlessness about her parents'
separation.
  Therapist uses interpretations to help child consciously process emotions.

Humanistic Play Therapy

 Also called "child-centered" play therapy.

 Focuses on emotional experience, not unconscious processes.
 Rarely uses interpretations.
 Therapist reflects feelings and fosters unconditional acceptance.
 Goal: Facilitate self-actualization through unconditional positive regard.
 Children develop self-acceptance and congruence between real and ideal selves.
 Example: Cassandra's therapy would emphasize acceptance and emotional experience without direct
interpretation.

How Well Does Psychotherapy for Children and Adolescents Work?

General Efficacy

 Psychotherapy for children and adolescents is quite effective.

 Children and adolescents who undergo therapy show significant improvement compared to those who
do not.
 Behavioral treatments often have a slight efficacy edge over nonbehavioral approaches.
 Massive meta-analysis (Weisz et al., 2017):

 Spanning 50 years, over 30,000 clients, 400+ studies.

 Findings:

 Kids receiving therapy had a 63% better outcome chance than those untreated.
 Best outcomes for anxiety disorders.
 CBT produced more consistently positive outcomes from kids', parents', and teachers'
perspectives.

Specific Findings

 Researchers now focus on specific therapies for specific problems.

 Cognitive-behavioral therapies (CBT) show strong empirical efficacy for:

 Anxiety disorders
 Oppositional defiant disorder
 Depression
 Hyperactivity
 Enuresis (bedwetting)
 School refusal
 Sleep disorders

 Play therapy shows benefits for a range of externalizing and internalizing disorders but with more
methodological shortcomings compared to CBT.

Effective Techniques for Specific Disorders

  Systematic desensitization, modeling, and cognitive restructuring:

 For phobia and other anxiety disorders.

 Exposure and response prevention:

 For obsessive-compulsive disorder (OCD).

 Parent-training techniques:

 For oppositional defiant disorder and conduct disorder.

 Parent training and classroom contingency management:

 For ADHD.

 Cognitive-behavioral techniques and interpersonal therapy:

 For childhood depression.

CHAPTER SUMMARY

 Clinical child and adolescent psychologists address a wide range of psychological issues.
 Assessments involve multiple sources, methods, and settings.
 Therapy approaches must be developmentally sensitive.
 Cultural competence is a key component in both assessment and therapy.
 CBT and parent training are highly effective treatments.

Notes prepared by: Angelica Grace Sumalinog