CBT WITH ADOLESCENCE

By: Beenish Nawaz Sara Ismail

WHAT IS ADOLESCENCE?

A series of major psychological adjustments have to be negotiated during adolescence.

Changing relationships

Identity Vs Role confusionAn adult or a child

Excitement Vs SadnessFreedom and opportunities or loss of dependence and safety

RISK AND RESILIENCE

Exposure to stress and adversity and the ways that individuals cope with stress are central to understanding sources of risk and resilience to psychopathology in children and adolescents.

Stressful life events and chronic adversity, most notably poverty and chronic abuse during development are powerful, nonspecific predictors of internalizing and externalizing symptoms and disorders.

COPING

Three-factor control-based model of coping for children and adolescents: Primary control engagement (problem solving,

emotional modulation, emotional expression) Secondary control engagement (acceptance,

cognitive reappraisal, positive thinking, distraction) Disengagement (cognitive and behavioral avoidance,

denial, wishful thinking).

(Compas et al., 2001, in press; Connor-Smith et al., 2000; Rudolph, Dennig, & Weisz, 1995)

The ability to cope with stress is a potential source of resilience.

Integration of coping and emotion regulation Differentiating between primary and secondary emotions

Coping versus Emotional Regulation Coping typically refers to the down-regulation of a negative emotion while emotion regulation also includes the maintenance or augmentation of a positive emotion (Eisenberg, Fabes, & Guthrie, 1997).

ROLE OF PROTECTIVE FACTORS

Special Consideration When Working With Young People.

Parents can be involved in CBT as co-therapist, which includes being taught how to manage and address their child’s anxiety using CBT strategies.

Parental support with reward system tied to completing specific task can be help promote desired behaviors an increase the motivation for therapy tasks.

A separate parent/ care session can be useful if the formulation suggests that the factors such as parental expectations of the child or the way in which problematic behavior is modified or reinforced are maintaining the difficulties.

Prescribing solutions or deciding for the adolescent is avoided. They work jointly on the discovery of dysfunctional patterns in thinking, setting goals and deciding on activities. Collaboration is to be followed at all points in therapy.

CBT in adolescents involves the use of activities, worksheets and various other methods of communicating formulation, educating and increasing participation.

Respecting the child and family without any bias and promotion and supporting the highest level of development and autonomy in the child are some of the other important rules (Schetky 1995). The therapist additionally faces pressures to control the client and force compliance at the cost of the individuality of the client

To protect the privacy of the adolescent client and keep him/her informed about frequency of parent involvement.

. The exceptions to the rules of privacy and confidentiality are also to be made clear to the adolescent.

CBT WITH OTHER DISORDERS WITH ONSET DURING ADOLESCENCE Internalizing behavior is behavior that is over-controlled or

covert. It is characterized by anxiety, social withdrawal, and depression. "Shy" behaviors are hard to detect sometimes because they are not as obvious as externalized behaviors.

Externalizing behaviors are those that are under-controlled or overt. They are characterized by aggression, striking out against others, impulsive and disobedient behaviors, and delinquency. They are really obvious and easy to detect.

CBT WITH OTHER DISORDERS WITH ONSET DURING ADOLESCENCE

Externalizing Oppositional Defiant

Disorder Conduct Disorder Juvenile Delinquency

Internalizing Eating Disorder Depression Bipolar disorder Obesity (not in DSM) Adolescent separation anxiety.

Anxiety Disorder

Substance Abuse DisorderADHD

CASE STUDY : EMILY

Emily is 16 year old girl and referred by her GP who had been viewing her for depressed mood when Emily disclosed that she has been thing about killing herself.

When seen, Emily describes low mood, feeling tired all the time, gaining no pleasure from her usual interests, inability to sleep, not eating and having recurrent thoughts of taking an overdose of paracetamol. She has felt like this for 3 weeks now.

Before that Emily was the best she had ever felt. She was out every night with friends until 1 am and only needed 3 hours sleep at night to keep going.

In fact she was buzzing, her mind was racing and she could not stop talking, which had been funny at first but then became annoying to her friends.

She had fallen out with her friends after she made sexual advances towards their boyfriends, which is totally out of character for her.

Emily attendance at school had became erratic she was always in trouble with both teachers and pupils for inappropriate remarks and behavior. This period of felling high lasted for 2 weeks.

ASSESSMENT

Parents, the child and teachers were interviewed. Rating scales such as Child Behavoiur Checklist Parent Young Mania Rating Scale Or Parent General

Bahavoiur Inventory.

Silverman and Ollendick (2005), provide a comprehensive list of interview-based as well as self-report measures that can be used in adolescents.

FORMULATION

Emily is presented during a depressed episode but gives a clear history of an episode of mania with elated mood, pressure of speech, grandiosity, disinhibited behavior and reduced sleep. Therefore se has had the two mood episodes required by ICD-10 criteria.

In addition, nice guidelines (2006) are clear that bipolar disorder is only diagnosed in presence of mania with euphoria in children and adolescence

In the adolescent age range, it is important to seek a history of substance abuse, as rates of the use of illegal substance are high and they can be responsible for a presentation like this.

Substance abuse disorder are present in 60 percent of adults with bipolar disorder (Cassidy et al, 2001) and 32 percent of young people have a life time history of substance abuse disorder ( Wilens etal , 2004)

INTERVENTION

Emily will needed treatment for depression as that is her presenting illness

The nice guidelines recommend 4 weeks of treatment with psychological therapy e.g CBT with medication.

CBT With Bipolar Disorder Session Plan

Initial sessionsInformation/development of therapeutic alliance

Socializing to therapy/goal setting

Intermediate sessionsMood monitoring

Understanding the relationship between mood and activity

Challenging the positive thoughts

Working with unrealistic positive ideas

Reframing

CBT With Bipolar Disorder Session Plan Final sessions Coping with early signs Identifying early, middle and late warning signs Pairing early warning signs with coping skills. Long term issues

HELP THEM STAY HOPEFUL

COMMONLY USED INTERVENTIONSThree main types cognitive restructuring

coping skills training (CST)

problem-solving skills training (PSST)

Specific techniques Arousal reduction methods. Applied relaxation (AR) Exposure and Response

Prevention (ERP) Graded exposure Social skills training (SST) Assertiveness skills The Coping Cat programme

REFERENCES

Case….. Margaret Thompson, Christine hooper, Child And Adolescent Mental Health Theory And Practice

Case formulation Cognitive Behavioural therapy …. Nicholas tarrier and Judith jhonson

Beauchaine, Hinshaw:Child and Adolescent Psychopathology, 2nd Edition Risk and Resilience in Child and Adolescent Psychopathology: Processes of Stress, Coping, and Emotion Regulation

QUESTIONS PLEASE