COLLABORATION ON CRITICAL QUESTIONS IN CHILD PSYCHOTHERAPY: A MODEL LINKING REFERRAL, ASSESSMENT, INTERVENTION, AND EVALUATION.

COLLABORATION ON CRITICAL QUESTIONS IN CHILD PSYCHOTHERAPY: A MODEL LINKING REFERRAL, ASSESSMENT, INTERVENTION, AND EVALUATION. SOCIAL WORKERS HAVE ALWAYS BEEN interested in helping clientschange. The evolution of new modes of intervention has facilitated rapidoutcomes on the one hand (Marks, 1987; Ost, Salkovskis, & Hellstrom,1991) and an increase in emphasis on valuative and comparative studiesof treatment efficacy on the other hand (Garfield, 1983; Kazdin, 1982,1986). The issues of the client's right to effective treatment andthe therapist's responsibility to provide that treatment havegained crucial attention in psychotherapy psychotherapy,treatment of mental and emotional disorders using psychological methods. Psychotherapy, thus, does not include physiological interventions, such as drug therapy or electroconvulsive therapy, although it may be used in combination with such methods. in general and in social workin particular (Alford & Beck, 1997; Bergin & Garfield, 1994;Bloom, Fischer, & Orme, 1995; Chambless et al., 1996; Curtis, 1996;Giles, 1993; Klerman, 1990). Myers and Thyer (1997) identify several ways for clinicians tofacilitate effective treatment. Among them are: using criteria from theTask Force on Promotion and Dissemination of Psychological Procedures(1995), employing stages to categorize cat��e��go��rize?tr.v. cat��e��go��rized, cat��e��go��riz��ing, cat��e��go��riz��esTo put into a category or categories; classify.cat empirical validation An empirical validation of a hypothesis is required for it to gain acceptance in the scientific community. Normally this validation is achieved by the scientific method of hypothesis commitment, experimental design, peer review, adversarial review, reproduction of results, (Curtis,1996), basing treatments on outcome studies (Chambless et al., 1996;MacDonald, Sheldon, & Gillespie, 1992), or learning frommeta-analyses (Gorey, 1996; Kazdin, 1988). Schools of social work have contributed to the dialogue andresearch on effective treatment strategies in a number of ways: (1)achieving a clearer and more concrete definition of target problems(Stein & Gambrill, 1977); (2) demonstrating a greater willingness topursue goals of a modest scope (Reid, 1978); (3) instituting baselineand outcome measures (Kazdin, 1988); and (4) the inclusion of all of theabove in social work studies and professional training (MacDonald etal., 1992; Tutty tut��ty?n. pl. tut��tiesAn impure zinc oxide obtained as a sublimate from the flues of zinc-smelting furnaces and used as a polishing powder. , 1990). One of the largest populations with whom social workers areinvolved are children, who encompass more than 50% of referrals tosocial welfare services. Recent epidemiological studies indicate thatfrom 17% to 22% of children and young people under 18 years of agesuffer from developmental, emotional, or behavioral problems (Kazdin,1994). Children are a population at high risk for developing behavioraland emotional problems for several reasons: 1. The normal basis of most childhood disorders. The majority ofchildhood disorders begin as developmentally normal problems and becomedeviant when they persist longer than expected (e.g., bed-wettingbecomes enuresis enuresisRepeated urination into bedding or clothing, usually at night, in a normal child old enough to have completed toilet training. Enuresis may be voluntary or involuntary. It may run in families. ) or when they increase instead of decrease in frequency(e.g., sleep problems become sleep terror disorder sleep terror disorderNight terror, pavor nocturnus Sleep disorders An abrupt awakening from sleep with behavior consistent with terror–panic, sweating, tachycardia, confusion, and poor recall for the event; STD occurs during stage 3/4 (deep) sleep, and is ) (Mash & Terdal,1988; Ronen, 1997). 2. Spontaneous developmental changes. Children undergo constant andrapid changes in motoric, emotional, and cognitive skills. Thisinstability can be at the root of children's behavioral andemotional disturbances (e.g., mood shifts and anger in adolescence). 3. Children's dependence on and vulnerability to caregivers.In addition to the development of independent childhood disorders, manychildren are in need of intervention due to difficulties in theirinteractions and relationships with others, usually adults, in theirenvironment. This situation is exacerbated when those same adults whoshould be protecting children are the ones responsible for theirdistress (e.g., by neglecting and abusing them). In view of the fact that one of the critical predictors of adultmental health problems is childhood disorders (Kazdin, 1988), the issueof applying effective intervention in childhood and adolescence becomescrucial. Kazdin's review of over 230 different techniques for childand adolescent therapy revealed that the great majority of thesetechniques have never been studied and, therefore, have never been shownto be effective. Throughout their growing years, children encounter manyprofessional figures (e.g., nurses, teachers, counselors, educators,pediatricians), but social workers in social welfare agencies are theonly figures who assist children with personal or familial difficultiesthroughout all their life circles--family, school, peers--and at allstages of their development--infancy, childhood, adolescence, andadulthood (Ronen, 1995b, 1998; Rose & Edelson, 1988). Social workersalso play multiple roles: as the professionals who serve in a protectiverole to ensure children's welfare, as direct interventionists withchildren and families, and as the link or mediator between all the otherfigures who are involved in a child's treatment at differentintervals (Ronen, 1994; Sheldon, 1987, 1998; Wolf, 1988). In light of social workers' unique role throughoutchildren's many life cycles and developmental stages, cliniciansought to be should be interested in furthering their understanding ofthe wide variety of roles and objectives among child therapists and inattempting to find areas of common ground to improve interdisciplinarycommunication and cooperation. This article offers social workers who are primarily involved inthe direct treatment of children and families a route to applyingeffective interventions in their day-to-day work. Workers involved inassessing and referring children to other kinds of treatment or in casemanagement may also benefit. The first part of this article highlightsthe diversity that characterizes child therapy and suggests thatuncovering areas of commonality might help the cooperation betweenprofessional disciplines and theoretical orientations, and contribute toadvancing children's welfare. In the second part, social andcognitive developmental considerations are suggested as areas ofconsensus for clinicians, and a model for effective treatment isproposed, encompassing a series of critical questions related to thedecision making process that links the referral, assessment,intervention, and evaluation of children. Consideration of consensual areas and critical basic questions isclearly important for the beginning social work student; however, theirvalue for the experienced social worker should not be overlooked. Eventhe most experienced professionals are devoted, and rightly so, tosharpening their skills in their own areas of expertise. This article isintended to help clinical social workers to ask and reframe Re`frame´v. t. 1. To frame again or anew. basicquestions from their present professional or theoretical reference pointrelative to the commonalities between social workers and other helpingprofessionals. Such critical self-assessment enables social workers toobserve their own professional development within the contextualrealities of working in their field of expertise. Identifying Common Areas of Agreement in Child Psychotherapy Mental health interventions for children vary with respect to the problem being addressed and to the age and other individual characteristics of the child. Although such interventions share some approaches, treatment methods can be quite different from each other. Child therapy is characterized by diverse theoretical orientationsand therapeutic techniques, as well as diverse professionals who areinvolved in treating children (Kazdin, 1988). Different therapeuticorientations target different areas, techniques, and goals forintervention, precluding the existence of one intervention that canserve as the treatment of choice for all children. An example of theoretical differences can be reflected in thevarious existing explanations for child disorders. The psychodynamic PsychodynamicA therapy technique that assumes improper or unwanted behavior is caused by unconscious, internal conflicts and focuses on gaining insight into these motivations.Mentioned in: Group Therapy, Suicide approach views emotional and behavioral symptoms as the manifestationsof underlying, internal emotional conflicts (Freud, 1971; Tolpin, 1978).The client-centered approach has formulated the self-esteem model, wherethe child's maladjustment maladjustment/mal��ad��just��ment/ (mal?ah-just��ment) in psychiatry, defective adaptation to the environment. mal��ad��just��mentn.1. Faulty or inadequate adjustment.2. is viewed as a reflection of anincongruence in��con��gru��ent?adj.1. Not congruent.2. Incongruous.in��congru��ence n. or split between the child's inner self and the selfpresented in everyday interaction (Rogers, 1942; Shirk shirkIn Islam, idolatry and polytheism, both of which are regarded as heretical. The Qu'ran stresses that God does not share his powers with any partner (sharik) and warns that those who believe in idols will be harshly dealt with on the Day of Judgment. & Russell,1996; Wright, Everent, & Roisman, 1986). In cognitive behavioraltheory on the other hand, children's maladjustment is viewed eitheras resulting from distortions in the individual child'sinterpretive activity or from a lack of basic cognitive skills forcontrolling behavior (Beck, 1976, 1987; Clark, 1995; Kendall &Braswell, 1985). Thus, it is impossible to consolidate one generaldefinition of child psychotherapy, to choose the most effectiveintervention for the specific child, or to decide who should best beinvolved in the treatment of a specific problem. Instead, therapists and educators can avoid confusion that mayarise over the synthesis of different theoretical approaches through theadaptation of shared standards or guidelines underlying childpsychotherapy within the mental health community. Finding common groundin child psychotherapy will make several contributions toward thedevelopment of such standards by promoting interdisciplinarycommunication and coordination, clarifying the most appropriateassessment and treatment for each individual child, and facilitating thedevelopment of pertinent research and scientific knowledge. Interdisciplinary Coordination and Communication A variety of professionals are involved in child interventions:teachers, counselors, clinical and educational psychologists, socialworkers, art therapists, nurses, pediatric pediatric/pe��di��at��ric/ (pe?de-at��rik) pertaining to the health of children. pe��di��at��ricadj.Of or relating to pediatrics. neurologists, psychiatrists,physical and occupational therapists, and other clinicians. While allthese professionals may view themselves as taking part in helpingchildren, it is often difficult to clearly define the uniquecontribution, role, responsibility, and limits of each discipline withinthe change process. For example, when a 5-year-old boy with selective mutism Selective mutism is a social anxiety disorder in which a person who is normally capable of speech is unable to speak in given situations. DescriptionIn the Diagnostic and Statistical Manual of Mental Disorders selective mutism is described as a rare psychological wasreferred to me for direct therapy, an abundance of therapeutic figureswere involved. He was enrolled in a special-education kindergarten classbecause of speech problems, received physical therapy due to some muscleweakness, and was learning to swim. All of the involved figures had beenchallenging him to begin talking and saw it as their role. During thistime, he had withdrawn more and more, and even stopped talking withthose to whom he had previously spoken, such as his parents andgrandparents. Change began only after we held a meeting where eachprofessional's goal was clearly defined: The kindergarten teacherswould be in charge of his learning; the physical therapist wouldconcentrate on strengthening his muscles; the swimming coach would focuson teaching him how to swim How to Swim is a cartoon made by the Walt Disney Company in 1942. In this cartoon, Goofy provides an educational treatise on swimming and diving with questionable results. ; and only I would address his talkingproblem in therapy. The formulation of a set of shared guidelines mayincrease therapists' sense of solidarity with other mental healthprofessionals--a much needed experience in the face of prevailinginterdisciplinary competition and dissension. Selection of Appropriate Treatments In their encounters with an overwhelming diversity of theories andmethods, therapists often tend to adhere to adhere toverb 1. follow, keep, maintain, respect, observe, be true, fulfil, obey, heed, keep to, abide by, be loyal, mind, be constant, be faithful2. the same familiar techniqueswhich dominated their academic training, or to which they were exposedin field practice (Sheldon, 1987). Sheldon accused clinicians ofcommonly "falling in love" with their methods instead ofconducting business relationships with them, as he perceived a tendencyfor clinicians to stop asking questions about their methods. Theformulation of a set of shared guidelines to assist therapists from allwalks of life in their decision making processes--from the time ofreferral, through assessment, treatment, and evaluation of treatmentoutcomes--may increase therapists' sense of control over theirchoices. Such guidelines could enhance their ability to select moreeffective methods according to according toprep.1. As stated or indicated by; on the authority of: according to historians.2. In keeping with: according to instructions.3. the individual needs of the particularchild, rather than their habitual, familiar preferences. Bridging Gaps in the Development of Research and ScientificKnowledge The selection of appropriate treatments becomes even more crucialsince researchers do not usually conduct therapy and vice versa VICE VERSA. On the contrary; on opposite sides. ,creating a gap in the relationship between research and intervention inthe field of child psychotherapy. Advances in research processes havecontributed to the development of more accurate assessment methods andthe empirical elucidation of internal, emotional processes. However,child psychotherapy has been characterized by the absence of systematicdialogue between child practitioners and clinical researchers (Shirk& Russell, 1996). Consequently, changes in research methods are notautomatically being reflected in therapy. In their book on psychologicalresearch and practice, Talley, Strupp, and Butler (1994) even describedopposing camps, claiming that the clinicians' perspective is thatresearch is not significantly informative to the therapeutic enterprise,while the researchers' view is that clinicians have turned a deafear to meaningful empirical findings. Another gap exists between the various interested professions thatis manifested as a lack of integrative knowledge. For example, educatorsandcounselors maintain expertise in learning processes that affectchildren; developmental psychologists and art therapists possesssignificant knowledge on developmental variables; social psychologists The following is a list of academics, both past and present, who are widely renowned for their groundbreaking contributions to the field of social psychology.: Top - 0–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y ZARobert P. focus mainly on social developmental process; nurses are very sensitiveto normal growth patterns as well as the effects of pain, sickness, anddisorder on children's growth; and social workers have much tooffer on understanding familial patterns and influences and therelations between the child and his or her environment. Although theformulation of one integrative view for all these areas of knowledgewould be infeasible, improved collaboration and communication betweenthe diverse professional disciplines would prevent this expert knowledgefrom remaining primarily in the hands of the different experts. Eachspecialization has much to offer in enriching the others and leading toqualitative changes in understanding and helping children. A Proposed Common Base in Child Psychotherapy--DevelopmentalConsiderations Despite the broad range of therapeutic approaches and widediversity of techniques for diagnosis and treatment, there are stillcommon areas that can be agreed upon Adj. 1. agreed upon - constituted or contracted by stipulation or agreement; "stipulatory obligations"stipulatorynoncontroversial, uncontroversial - not likely to arouse controversy by most professionals involved inthe direct, individual treatment of children. These areas--relatedmainly to developmental considerations, normal growth patterns, andsocial influences--can serve as a strong basis for interdisciplinarycommunication, mutual enrichment, and increased treatment efficacy forapproaches that focus on individual dysfunction. Such approaches viewthe child's problem as related mainly to the child'sdevelopment and personality structure and only secondarily to familialand social systemic components. Development theories refer to the changing structure of behaviorover the lifespan, indicating not only changing degrees of organismiccomplexity, but also changes in the biological and psychologicalsubstructures emerging and unfolding in social surroundings (Shapiro,1995). All theoretical orientations recognize the importance of agewhile considering treatment processes. Older children have greateremotional understanding as well as the ability for stronger egoconsolidation. Effective intervention with children should, therefore,directly relate child disturbances to developmental considerations. Onlythrough knowledge of normal developmental processes can one begin tounderstand deviations in development and their importance for assessmentand intervention (Forehand forehandthe head, neck, shoulders, withers and forelimbs of the horse. & Weirson, 1993). Children's cognitive developmental levels are also importantin the genesis and maintenance of maladaptive MaladaptiveUnsuitable or counterproductive; for example, maladaptive behavior is behavior that is inappropriate to a given situation.Mentioned in: Cognitive-Behavioral Therapy and adaptive behaviors(Beidel & Turner, 1986) and as moderators in the efficacy ofimplementing specific kinds of therapy (Durlak, Fuhrman, & Lampman,1991). For example, Dush, Hirt, and Schroeder (1989) found a positiverelationship between age and treatment outcome in cognitive therapy cognitive therapyn.Any of a variety of techniques in psychotherapy that utilize guided self-discovery, imaging, self-instruction, and related forms of elicited cognitions as the principal mode of treatment. withchildren, where older children having more advanced cognitive skillsbenefitted more from treatments. The best results were found foradolescents (aged 13 to 18 years) and good outcomes were shown forpreadolescents (aged 11 to 13), but only one half the success rate wasdemonstrated with younger children (aged 5 to 11). In addition to age considerations, several other assumptions areaccepted by all theoretical orientations, for example, that children arereferred to psychotherapy due to difficulties in functioning. Thearguments remain based on whether the dysfunction (e.g., enuresis,aggressiveness, social rejection) should be viewed as the focus ofintervention or whether these symptoms pinpoint deeper internal problemsto be treated. All the different theories also agree that children donot respond directly to their interpersonal environment. Instead, it isassumed that internal psychological processes mediate between the socialworld and the child's emotional experience and overt behavior. Atthe same time, all orientations agree that whenever the child isreferred, the family is involved. Much of child intervention focuses onparents or environmental counseling; however, even if direct therapy isapplied, parents are invariably in��var��i��a��ble?adj.Not changing or subject to change; constant.in��vari��a��bil involved. In addition, all modes accept the view that behavior is related tothoughts and emotions and agree that treatment must address theseconnections. The differences lie in conceptualizing which part of thisrelationship is targeted as a focus for change. Behavioral therapistsexpect behavioral changes to be responsible for alterations in thoughtsand emotions. Psychodynamic therapists view behavior changes as anoutcome of shifts in internal processes, indicating the need to treatdrives and motives and to wait for behaviors to change themselves asinternal emotions become better understood. A generic aim ofpsychotherapy accepted by all would be to restrict or remediate internalpsychological processes (Shirk & Russell, 1996). Finally, allpsychotherapeutic psy��cho��ther��a��py?n. pl. psy��cho��ther��a��piesThe treatment of mental and emotional disorders through the use of psychological techniques designed to encourage communication of conflicts and insight into problems, with the goal being approaches uphold that the treatment of children is aprocess where the therapist listens to the child, encourages thechild's expression within a warm and accepting climate, andclarifies and interprets the child's verbal and nonverbalcommunication nonverbal communication'Body language', see there in order to achieve change (Shirk & Russell, 1996). The next section deals with guidelines to help therapists plantheir intervention process based on the above developmentalconsiderations. The therapist's decision making during childintervention comprises a constant process of asking questions, beginningat the referral and assessment stages, continuing throughoutintervention, and culminating in the stage of maintaining and evaluatingtreatment outcomes. Even the experienced therapist can benefit from areexamination re��ex��am��inealso re-ex��am��ine ?tr.v. re��ex��am��ined, re��ex��am��in��ing, re��ex��am��ines1. To examine again or anew; review.2. Law To question (a witness) again after cross-examination. of these basic questions throughout the decision makingprocess, and increased awareness to the child's problems focused onthis process, rather than decisions by rote rote?1?n.1. A memorizing process using routine or repetition, often without full attention or comprehension: learn by rote.2. Mechanical routine. . Those questions aim atlinking assessment to intervention and facilitating effectiveintervention. The proposed guidelines provide a sequence of questionsreflecting the major decisions encountered by the child psychotherapist psy��cho��ther��a��pistn.An individual, such as a psychiatrist, psychologist, psychiatric nurse, or psychiatric social worker, who practices psychotherapy. :Does this child need therapy or not? (Phase 1) How can this child'sreferral and goals for change be classified? (Phase 2) Which assessmentmethods should be selected? (Phase 3) What is the right setting fortreatment? (Phase 4) What is the optimal kind of intervention? (Phase 5)What outcome was achieved by treatment (Phase 6) Phase 1: Deciding on the Need for Therapy The first phase in any intervention process is deciding whether thereferred child's presented problem actually necessitatesintervention. As can be seen in Table 1, to determine the necessity fortherapy the decision making process must address four sets of questionsto be asked by the clinician, concerning problem variables,developmental and environmental variables, child and family variables,and prognostic prog��nos��ticadj.1. Of, relating to, or useful in prognosis.2. Of or relating to prediction; predictive.n.1. A sign or symptom indicating the future course of a disease.2. variables (Ronen, 1997).Table 1. Phase 1: Decision Making on the Need for TherapyReferred Problem Variables1. Does the problem fit diagnostic criteria?2. Has the problem worsened? Remained stable? Improved?3. Does it pose a risk to the child's future?Developmental and Environmental Features of the Problem1. Is the problem deviant among the child's same-age peers?2. Is the problem deviant for the child's sex group?3. Is the problem deviant in the child's environment (e.g., notpart of cultural or environmental norms)?Child and Family Variables1. Does the child (and family) have motivation for change?2. Are there adequate support systems (familial or social)?3. What are the chances of developing a good therapeuticrelationship with the child (and family)?4. How is the child's emotional state affected by the problem?Prognostic Variables1. Is there a good prognosis for treating this specific problem?2. Can the child improve without therapy?3. Will the child be different after therapy? The first set of questions relates to the nature of the referredproblem. Through their growth, children experience a high frequency ofbehavioral problems (such as age-related fears, or rebelliousness asthey start to mature and develop their own identity). Often, theseproblems disappear without treatment (Ronen, 1993a, 1993b, 1997). As ageneral rule, a problem should be treated if it fits recognized clinicaldiagnostic criteria, if its frequency is increasing (or at times,remaining stable), and if it poses a risk to the child's future.Careful collection of historical data on the referred problem'sfrequency and stability and use of diagnostic references will providethe information necessary to determine if treatment is indicated. The second set of questions relates to developmental andenvironmental features. It is impossible to decide whether or not thechild needs therapy without comparing the presented problem to thechild's age and sex group and to social norms. For example, a9-year-old boy was referred to me because he was acting "toochildish." Yet during assessment it emerged that, due to his highintelligence and academic achievement, he had been placed in an academicstudy group at school with children two years his senior. His parentsand teacher were expecting him to behave like these older children, butemotionally he was acting appropriately--like the 9-year-old that hewas. Another example is of a child whose teacher thought he was actingsuspiciously, almost paranoid. It turned out that this boy was a newimmigrant from a country where the political atmosphere necessitatedmistrust and intense interpersonal scrutiny, and his behavior mirroredthe behavior of other children in his age group from his country oforigin. It was a norm, not a pathology. If a child's problem deviates from the age, sex, and culturalnorms as well as from the child's age and sex group, this indicatesthat therapy is warranted, especially if the immediate environment(family) is seeking treatment. All these developmental components havean impact on the therapist's decision making process, not only indetermining the need for treatment, but also in all the other phases asdescribed below. The third set of questions relates to child and family variablesand the role of therapeutic relationships, which have crucialimplications for the success of clinical intervention. Motivationalattitudes are of great importance for decision making, considering theirinfluence on the child's coping and adjustment. For example, when aproblem is common in the environment, reflecting cultural norms orresulting from role modeling, there is often a low risk for thechild's well-being. Yet if the child views the problem as deviantor it disturbs the family, treatment can still be applied, even when theproblem does not meet the above criteria regarding its nature and itsdevelopmental and environmental features. Conversely, when motivation islacking in a case with high future risk, the first step of therapy willbe to identify any area of motivation in the client and use it toincrease motivation for change. Support systems can render an impact on a child's conditionand are therefore crucial for treatment. A major component forincreasing motivation is the therapeutic relationship. Children usuallyattain better grades in classes where they like the teacher. Similarly,feelings of trust, confidence, and motivation will increasechildren's cooperation, help them invest more effort, and empowerthem to try new experiences. The final child variable to be considered is the extent to whichthe child's emotional state is affected by the referred problem.When a child is being abused, a high risk for the child's future isobvious, clearly necessitating intervention. However, when thechild's problem is one such as enuresis, which does not pose aserious direct threat to development, answers may not be so clear-cut.An important criteria for decision making in such cases consists of thechild's emotional prognosis. Bed-wetting in itself will not harmthe child, but damage may arise to the child's self-esteem andsense of worth, and social withdrawal may result from embarrassment.Parental motivation to cease the nuisance of bed-wetting aside, thechild's own affective response should be examined. The fourth set of questions relates to prognostic variables. Theprobability of spontaneous recovery The introduction to this article provides insufficient context for those unfamiliar with the subject matter.Please help [ improve the introduction] to meet Wikipedia's layout standards. You can discuss the issue on the talk page. from the referred problem needs tobe weighed against the known success rates for its treatment. Often,even when the child does not express motivation but treatment is likelyto resolve the problem, reaching-out techniques will be used to attemptto activate the child toward change. However, when the prognosis for aproblem is only fair and the child unmotivated, there is a need to lookfor other ways (e.g., environmental change) to help the child. These guidelines must be evaluated integratively; for example, asevere problem with a poor prognosis and lacking family support maystill warrant treatment if the child is highly motivated and can developa good therapeutic relationship. Phase 2: Classification of a Child's Referral and Goals forChange The complexity of common child referrals to therapy includesproblems in: their personal functioning (e.g., enuresis, tics,stuttering stutteringor stammering,speech disorder marked by hesitation and inability to enunciate consonants without spasmodic repetition. Known technically as dysphemia, it has sometimes been attributed to an underlying personality disorder. , anorexia, trichotillomania trichotillomania/tricho��til��lo��ma��nia/ (-til?o-ma��ne-ah) compulsive pulling out of one's hair. trich��o��til��lo��ma��ni��an.A compulsion to pull out one's own hair. ); their relationships with theimmediate adult environment such as school and family (e.g.,disobedience, aggression, negativism negativism/neg��a��tiv��ism/ (neg��ah-ti-vizm?) opposition to suggestion or advice; behavior opposite to that appropriate to a specific situation or against the wishes of others, including direct resistance to efforts to be moved. ); or their peer relations (e.g.,social skill deficits, social withdrawal or rejection) (Achenbach, 1985;Hughes, 1993; Kazdin, 1988). Expressing the common wish to help childrenchange their behavior (Kratochwill & Morris, 1993), adults are mostoften the ones who bring children to treatment, primarily because ofbehavioral problems that disturb the surrounding adult population. Suchacting-out or "undercontrolled" problems as disobedience,aggressiveness, and impulsiveness do not necessarily disturb thechildren as much as the acting-in or "overcontrolled"disorders such as depression, anxiety, or loneliness, which are lessoften seen by clinicians (Mash & Terdal, 1988; Ronen, 1993a, 1993b,1997). Even when children who were victims of abuse or neglect at thehands of adults are referred, the presented behavior is typically of anacting-out nature, which disturbs adults. Table 2 presents children's four most common types of referralin terms of their inherent treatment goals (Ronen, 1995a, 1995b, 1997):(a) to decrease behaviors which the child presents too frequently, (b)to increase behaviors which the child does not present often enough, (c)to remove anxieties which create avoidant behavior, and (d) tofacilitate developmental processes. [TABULAR DATA 2 NOT REPRODUCIBLE IN ASCII ASCIIor American Standard Code for Information Interchange,a set of codes used to represent letters, numbers, a few symbols, and control characters. Originally designed for teletype operations, it has found wide application in computers. ] Often children do not suffer from one sole problem, and there aremany overlapping causes, kinds of problems, and types of treatment.Therefore, the classification presented in Table 2 should be used forpurposes of teaching, clarification, and emphasizing major trends. Children who need to decrease behaviors--the first type ofreferral--are characterized by a lack of self-control skills and animpulsive im��pul��siveadj.1. Inclined or tending to act on impulse rather than thought.2. Motivated by or resulting from impulse.im��pul manner of thinking and acting. Such undercontrolled children(Mash & Terdal, 1988) demonstrate difficulties in toleratingfrustration, delaying gratification, keeping attention on target, orusing problem-solving skills. They act without thinking or planning andlack careful information processing information processing:see data processing. information processingAcquisition, recording, organization, retrieval, display, and dissemination of information. Today the term usually refers to computer-based operations. in situations in which thinkingwould be beneficial (Kendall, 1993). On the other hand, children who need to increase theirbehaviors--the second type of referral--are overcontrolled children(Mash & Terdal, 1988) who are characterized by emotional dysfunctionand low self-confidence, self-acceptance, or self-esteem. They oftenoveremphasize o��ver��em��pha��size?tr. & intr.v. o��ver��em��pha��sized, o��ver��em��pha��siz��ing, o��ver��em��pha��siz��esTo place too much emphasis on or employ too much emphasis. self-evaluation, frequently setting themselves goals orcriteria that are too high and thereby underappreciating their ownachievements. Kendall (1993) suggested that such children are limited todistorted thinking distorted thinkingPsychology Any of a number of 'emotional traps' that prevent a person from addressing negative emotions Forms of DT All-or-nothing thinking, overgeneralization, mental filtering, personalizing blame. , where they misconstrue mis��con��strue?tr.v. mis��con��strued, mis��con��stru��ing, mis��con��struesTo mistake the meaning of; misinterpret.misconstrueVerb[-struing, -strued and misconceive mis��con��ceive?tr.v. mis��con��ceived, mis��con��ceiv��ing, mis��con��ceivesTo interpret incorrectly; misunderstand.mis socialsituations. Thus, interventions with these children should addressdistortions in their self-concept and should challenge them to do more,with a focus on experiencing and practicing. Children who suffer from anxiety--the third type ofreferral--cannot achieve their potential capabilities due to avoidanceand regression caused by their fears, anxieties, and trauma. Thesechildren need to acquire a wider repertoire of coping skills and topractice exposure assignments in order for them to try out newexperiences. For the last group of children, whose development needs to befacilitated due to their immaturity, treatment should promote theacquisition of new skills (e.g., to stop crying, restrain, takeresponsibility), offer practice in new tasks, and provide new models forchange. For example, a child can behave childishly due to a lack ofskills, but that could also be the result of a family who doesn'tgive the child a chance to be independent or to take on responsibility.Here again, the environment, especially the family, is of greatimportance for facilitating change. In weighing children's referrals and establishing treatmentgoals, this classification into four problem types can provide a solidframework acceptable to therapists from different theoretical approachesand professional disciplines. Yet this classification is incompletewithout taking into account the developmental components that are partand parcel of child intervention. To complement the problemclassification, Table 3 presents a second classification paradigm basedon the characteristics of children's referral, assessment,treatment, and evaluation in terms of four major developmental stages:infancy, early childhood, middle childhood, and adolescence. Again, thistable should serve as a general diagram to clarify major trends foreducational purposes. [TABULAR DATA 3 NOT REPRODUCIBLE IN ASCII] As can be seen in Table 3, children's referrals can beclassified into different kinds of problems that depend on cognitivelevel (Piaget, 1926) as well as the expected social tasks characterizingthe four developmental stages. Forehand and Weirson (1993) delineated de��lin��e��ate?tr.v. de��lin��e��at��ed, de��lin��e��at��ing, de��lin��e��ates1. To draw or trace the outline of; sketch out.2. To represent pictorially; depict.3. the specific treatment plan best suited to facilitating new roles ateach childhood age/stage in light of its major developmental socialtasks. During infancy, the major developmental task consists of shiftingfrom total dependence on the caregiver to increased independence andself-regulation, leading to a range of normal educational anddevelopmental difficulties. The major developmental task of earlychildhood--to begin mastery of academic and socialsituations--precipitates behavioral difficulties and disciplineproblems. From about age 9-12, the higher level of operational thinkingenables the development of an individual identity and of self-controlskills; therefore, problems in self-control and interpersonaldifficulties typify middle childhood. Finally, in adolescence, the majordevelopmental task is to establish separation and individuation individuationDetermination that an individual identified in one way is numerically identical with or distinct from an individual identified in another way (e.g., Venus, known as “the morning star” in the morning and “the evening star” in the from thefamily unit, seeking autonomy; thus, identity problems emerge at thisstage, as do difficulties in regulating the extent of independence fromand the quality of interaction with the family. Phase 3: Making Decisions on Assessment Methods Based on different conceptualizations of the referred problem,different theories use different assessment modes. For example, thepsychodynamic approach directs assessment toward uncoveringprecipitating conflicts; cognitive behavior theory Behavior theory can refer to: in sociology, the collective behavior theory in political sciences, the theories of political behavior in psychology, the theory of planned behavior bases assessment oncarefully identified objectives, target behaviors, and appropriatemethods of measurement; and the client-centered theory does not provideassessment at all in order to avoid questioning the child and tomaintain an accepting attitude. The predominant methods for child assessment are based onpsychological tests Psychological TestsDefinitionPsychological tests are written, visual, or verbal evaluations administered to assess the cognitive and emotional functioning of children and adults. (verbal, association) and projective pro��jec��tive?adj.1. Extending outward; projecting.2. Relating to or made by projection.3. Mathematics Designating a property of a geometric figure that does not vary when the figure undergoes projection. testing(drawing, reflecting), which inquire into the child's internalworld (Goldman, Engle Stein, & Guerry, 1983). Table 2 exemplifies how different assessment methods may be used inrelation to the kind of problem being treated and the kind of settingbeing selected for therapy. Table 3 provides examples of how theselected assessment tools and sources of information can be influencedby that child's age. Among the variety of assessment tools, thereis no right or wrong measurement, but often a standard, familiar batteryof tests is utilized, without much consideration of individual needs.Clinicians should get into the habit of asking themselves the question:Which kind of assessment is most likely to answer the presentedquestions being raised about this particular child at this particularage? Careful decision making on the types of assessment measures shouldbe based on the child's problem, the child's referral, and thegoals of therapy. At the same time, emphasis should be placed on thechild's cognitive level, expected social tasks, and the value ofdifferent information sources at various developmental stages. As the primary objective, tools should be selected to obtaindifferent information: To learn about the child's emotional state,projective methods are in order. To learn about the severity of specificdisorders, a specific inventory or scale could help. Another mainobjective to keep in mind is that assessment tools should be selected tofacilitate the intervention. The clinician should ask: How will thisspecific assessment tool change the way I plan to intervene with thechild? Will its different outcomes point to the need for different kindsof intervention settings, treatment methods, or techniques to be used? Phase 4: Selecting the Appropriate Setting for Intervention Selection of the optimal setting for intervention is alsoinfluenced by the four kinds of children's referrals (see Table 2).The child who needs to decrease behaviors usually does not suffer fromthe problem as much as the environment is disturbed by the child.Individual therapy with children who evidence acting out disorders istypically not as effective as trying to change the environment'sresponse to the child, as well as changing the environment itself. Themain target of intervention, therefore, is usually on supervisingparents or teachers or applying family therapy. In contrast, when the problem relates to overcontrolled behaviorsthat need to be increased in frequency, emotional features are oftenprominent. Therapy can help the child express emotions, overcome fears,depression, and guilt; ameliorate a��mel��io��rate?tr. & intr.v. a��me��lio��rat��ed, a��me��lio��rat��ing, a��me��lio��ratesTo make or become better; improve. See Synonyms at improve.[Alteration of meliorate. negative self-evaluations; and developa sense of self-efficacy and self-confidence (Ronen, 1998). The targetof intervention is mainly individual or group therapy for the child.Secondarily, supervising or counseling the environment may be needed. When the expected goal of therapy at referral is to remove anxiety,the child needs to express emotions, practice exposure to the fearedsituations, and be supported by the environment. The main settings,therefore, are individual treatment for imparting the child with theneeded skills for change, and parent counseling to enhance environmentalsupport. The fourth kind of problem, to facilitate development, can beachieved primarily via the environment. The child with immature behaviordoes not easily give up the role of a young child. Although sometimesthere is a need to directly impart the child with mature skills, thoseskills are usually acquired when the environment changes, increasesdemands, and gives the child added responsibilities. The kindergartenteacher can learn how to reinforce a mature behavior and ignore achildish one. Parents can learn to train their child in taking on tasksand roles in the family, and can reinforce positive behavior. Animportant role here can be played by peers, who may become involved tohelp the child learn new roles and behaviors. Other considerations for selecting the intervention setting arerelated to developmental features (see Table 3). During infancy,problems in gaining initial achievements in autonomy usually derive fromthe way the parents educate their child, and treatment should thereforefocus on parental counseling. Thus, when children are young anddependent on their caregiver, therapy usually has primary preventionaims (i.e., preventing future risk and reducing the incidence ofdisorder, Graham, 1994) and takes the form of counseling and supervisingparents in educating and rearing their children (Ronen, 1997). As children grow up and encounter the academic and social tasksinherent in school experience during early childhood, interventions mostoften involve parent and teacher supervision regarding theirrelationships and discipline methods, preferably in theirchildren's presence. Very rarely, children themselves are treateddirectly. Thus, therapy should be directed to the child within his orher natural environment (i.e., parents, teachers, and friends) andtoward educational-therapeutic assignments (i.e., secondary prevention,which prevents existing problems from worsening and reduces the durationof the disorder, Graham, 1994). From middle childhood to early adolescence, the child's searchfor personal identity and acquisition of self-control are taskssuggesting the need to implement individual or group therapy focusing onsocial support, self-evaluation, and acceptance. As children enter middle adolescence, the task of individuationfrom the family unit and moving toward autonomy requires directinterventions with the adolescent to help in developingindividualization individualization,n the process of tailoring remedies or treatments to cure a set of symptoms in an indiv-idual instead of basing treatment on the common features of the disease. , self-acceptance, and problem solving problem solvingProcess involved in finding a solution to a problem. Many animals routinely solve problems of locomotion, food finding, and shelter through trial and error. skills. Thus,adolescents' therapy should focus on tertiary prevention tertiary preventionMedtalk Treatment that alters the course of clinical disease--eg, with CABG or PCTA. See Percutaneous transluminal coronary angioplasty Psychiatry Measures to reduce impairment or disability following a disorder–eg, through rehabilitation. which aimsto resolve an already existing problem, prevent future risks, and impartskills for decreasing its frequency; therapy covers rehabilitative re��ha��bil��i��tate?tr.v. re��ha��bil��i��tat��ed, re��ha��bil��i��tat��ing, re��ha��bil��i��tates1. To restore to good health or useful life, as through therapy and education.2. activities and reduces the disability arising from an establisheddisorder (Graham, 1994). As can be seen, no problem should be treated by focusing only onone setting, but rather on a combination of settings that considerdevelopmental factors. As a general rule, when a child exhibits behaviorproblems (needing to decrease behaviors or facilitate development) or isyoung in age, the targeted client system is often the environment (e.g.,parent counseling). In contrast, when the child suffers from emotionalproblems (needing to increase behaviors or remove anxiety) or is inmiddle childhood and up, the child is typically targeted for individualintervention (usually along with parent counseling). It should be notedthat in extreme cases (e.g., child abuse), social workers appropriatelytarget the environment by placing children into new, supportivesurroundings. However, these environmental interventions in themselvesare generally insufficient; direct treatment of the child is alsousually necessary to help the child with emotional problems, changenegative attitudes, and promote self-confidence and trust. In addition,the new environment--whether it be foster care or an adoptive a��dop��tive?adj.1. a. Of or having to do with adoption.b. Characteristic of adoption.2. Related by adoption: home--certainly requires guidance, support, and counseling in how tocope with the special difficulties inherent in such a transition andwith the long-term effects of trauma and abuse on the child. Phase 5: Making Decisions about Treatment Methods The selection of appropriate therapeutic modes for children willtake into account a number of referral and assessment variables (seeTable 2): the characteristics of the child's specific disorder, thekinds of behaviors and deficits presented, and the negative impact thesehave caused to the child, the environment, or both. The optimaltreatment method should be selected only after the carefulidentification of the treatment's expected goal (i.e., decreasing abehavior, increasing a behavior, removing anxiety, or facilitatingdevelopment), focus (e.g., behaviors, emotions, cognitions), and thetargeted client system (e.g., child, parents, teacher). Whileconsidering the focus of intervention, one should remember that nochange is exclusively behavioral, emotional, cognitive, or interpersonalin its nature (Shirk & Russell, 1996). Interrelations exist betweenall realms, affecting one another; therefore, intervening in one realmresults in changes in the others. For example, a boy undergoing abehavioral treatment because of his lack of assertiveness will betrained in standing still, talking loudly, and maintaining direct eyecontact (Bandura ban`dur´an. 1. A traditional Ukrainian stringed musical instrument shaped like a lute, having many strings. , 1969). Changes will occur not only in his behavior,but also in his emotions. While enacting a self-confident stance, hewill begin to feel more secure. Or, a girl with enuresis who is changingher emotions in psychodynamic play therapy will also learn to change herbed-wetting behavior. The selection of methods for intervention also crucially depends onthe therapist's theoretical approach, and the age, sex, and majordevelopmental (cognitive and social) tasks facing the child. Thetheoretical understanding and the basic research available ondevelopment indicate that, at different ages and stages of developmentand differentially for boys and girls boys and girlsmercurialisannua. , specific processes andopportunities may emerge in domains such as cognitive comprehension,exposure to new experiences, establishing relationships, perceiving andexpressing emotions, etc. Research on cognitive development, peerinfluences, and transition periods (e.g., transferring schools,adolescence) suggests the need for different sorts of intervention toachieve change (Kazdin, 1991). Therefore, the selection of assessment,treatment, and evaluation techniques should clearly discriminate betweendevelopmental factors as presented in Table 3. For instance, based on theoretical grounds, psychodynamic therapy Psychodynamic therapyA therapeutic approach that assumes dysfunctional or unwanted behavior is caused by unconscious, internal conflicts and focuses on gaining insight into these motivations.Mentioned in: Cognitive-Behavioral Therapy frequently utilizes indirect methods due to children's variabilityin their capacity for verbalization (Klein, 1975). Main techniques usedare play therapy, interpretation, and the provision of a correctiveexperience by creating help, support, encouragement, and a sympatheticenvironment (Freud, 1968). Client-centered therapy is nondirective(Axline, 1947); rather than utilizing specific therapeutic techniques,the principle vehicle of change is the free, permissive permissiveadj. 1) referring to any act which is allowed by court order, legal procedure, or agreement. 2) tolerant or allowing of others' behavior, suggesting contrary to others' standards. PERMISSIVE. therapeuticrelationship and the warm, receptive attitude of the therapist, whichenable the child's emotional expression and reduce the child'sdefensiveness (Shirk & Russell, 1996). Cognitive behavioral therapy cognitive behavioral therapyn.A highly structured psychotherapeutic method used to alter distorted attitudes and problem behavior by identifying and replacing negative inaccurate thoughts and changing the rewards for behaviors. is a structured, goal directed, time limited, and problem orientedprocess aimed at fostering change both by applying verbal communicationand by practicing and experiencing methods (Kazdin, 1991; Kendall, 1993;Rosenbaum & Ronen, 1998). The selection of treatment methods is perhaps most influenced bydevelopmental considerations. As described above, infants and youngchildren are not usually treated directly, but rather their parents aresupervised through verbal communication in how to change theirchildren's behavior. The most popular treatments for parents followeither the humanistic theories or behavioral methods. In earlychildhood, when children become candidates for group or individualtherapy, nonverbal non��ver��bal?adj.1. Being other than verbal; not involving words: nonverbal communication.2. Involving little use of language: a nonverbal intelligence test. indirect methods such as art, play, or music therapyare often the treatments of choice. Children of this age are frequentlyoffered psychodynamic play therapy, behavior therapy behavior therapyor behavior modification,in psychology, treatment of human behavioral disorders through the reinforcement of acceptable behavior and suppression of undesirable behavior. , or cognitive playtherapy (Ellinwood & Raskin, 1993; Klein, 1975; Knell knell?v. knelled, knell��ing, knellsv.intr.1. To ring slowly and solemnly, especially for a funeral; toll.2. To give forth a mournful or ominous sound.v.tr. , 1993; Ronen,1992, 1995a; Tuma & Russ, 1993). At middle childhood, when childrencan benefit from verbal therapy verbal therapy1 Imagineering, see there 2 Talking therapy, see there as well, indirect methods such asbibliotherapy bibliotherapy/bib��lio��ther��a��py/ (bib?le-o-ther��ah-pe) the reading of selected books as part of the treatment of mental disorders or for mental health. bib��li��o��ther��a��pyn. are still often used. When verbal therapy is involved, itusually includes many demonstrations and exercises, along with imagery,metaphors, or day-to-day examples. Only in adolescence does most therapybecome verbal and direct, involving adolescents in talking about theissues of most concern to them. At this stage, youngsters canparticipate in a wider range of treatments, including verbal, nonverbal,direct, and indirect methods. Phase 6: Evaluating Treatment Outcomes The ultimate goal of any treatment is to attain a curative curative/cur��a��tive/ (kur��ah-tiv) tending to overcome disease and promote recovery. cu��ra��tiveadj.1. Serving or tending to cure.2. effect,whether in the form of achieving behavioral improvement, emotionalchange, or symptomatic relief, or learning needed skills, or increasingindependent functioning in the future. Thus, considering thetreatment's outcome must be an integral part of any intervention.Evaluation methods are of great importance to learn about the efficacyof a specific intervention, the particular change process, and theindividual's state after treatment (Kazdin, 1982, 1991). Evaluationof treatment outcomes includes studies that consider general groupchanges as well as single case designs that examine individualdifferences. The selection of evaluation methods should be based on the goal oftreatment as well as developmental considerations. Generally, evaluationshould consider checking both the child and the environment andcomparing the reports from the different sources to obtain a fullpicture of the kind of change that occurred (Achenbach, 1993). Treatment evaluation should address three main areas. First andforemost, behavior change Behavior change refers to any transformation or modification of human behavior. Such changes can occur intentionally, through behavior modification, without intention, or change rapidly in situations of mental illness. is evaluated to determine whether or not thedisorder that led to referral has been eliminated. Behavioralquestionnaires directed to the child and to parents or teachers canprovide this information. Second, there is the question of emotionalchange. Studies have shown that parents are good sources for evaluatingchildren's behavior, but not their emotions (Angold et al., 1987;Hodges, Gordon, & Lennon, 1990; Reid, Kavanagh, & Baldwin,1987). Therefore, self-report measures can provide affective informationthrough verbal questionnaires (e.g., on anxiety, loneliness, depression,etc.) or through indirect, projective methods such as drawing or formalprojective testing. Third, cognitive changes in perceptions, attitudes,and thinking style can be directly assessed through attitude scales,self-efficacy questionnaires, etc. Summary: Bridging the Gaps between Research and Intervention Social workers use a broad range of theoretical orientations andtreatment methods for resolving children's problems, and they workwith professional colleagues from many disciplines. It would beinfeasible to assemble one unified, agreed-upon practice for assessing,intervening with, or evaluating the treatment of children'sdisorders. However, this article proposes a set of widely acceptableguidelines for child therapy that focus on childhood elements anddevelopmental considerations which are shared by all professions andinclude the diversity of social work roles. The view of childhood as a period when major developmental tasksare achieved unites all child therapists, notwithstanding the causes,explanations, and treatment methods suggested by their basic theoreticalorientations. The developmental considerations serve as common ground indetermining how referral, assessment, treatment, and evaluationprocesses should be designed, and may foster cooperation andcommunication among clinicians as well as researchers, with the ultimategoal of strengthening treatment efficacy. This article proposes guidelines for effective intervention withchildren. In encountering the specific referral, therapists should askthemselves: What uncertainties do I have concerning this child? Does thechild genuinely need therapy? How can I plan the assessment to maximallyprovide the information I need to understand the child'sdifficulties and design the best treatment for this particular child?What kind of treatment will best suit the child's needs and modifythe child's present coping style? What kind of changes are neededand, therefore, what kind of goals should I establish for theintervention? And, finally, at the end of treatment, what kind ofchanges have been achieved and have the treatment objectives been met? While using the proposed set of guidelines, discrepancies willstill emerge between those therapists who think that a child'senuresis, for example, is primarily a symptom that reflects negativefeelings toward the parents, indicating play therapy as optimal, andthose who believe that enuresis is a problem necessitating theimplementation of elimination techniques. However, using the currentguidelines, both groups of therapists will increase awareness of theneed to explain how they conceptualize con��cep��tu��al��ize?v. con��cep��tu��al��ized, con��cep��tu��al��iz��ing, con��cep��tu��al��iz��esv.tr.To form a concept or concepts of, and especially to interpret in a conceptual way: the referred case, what they aregoing to do and why, and how they will know if they reach their goalsand treatment should end. In addition, both groups will increase theirunderstanding that clinicians from different orientations anddisciplines share common guidelines and significant areas of consensus.These areas relate to widely accepted assumptions on developmental dataas opposed to diverse theoretically oriented research. Understandingthese commonalities within the larger knowledge base of child therapycan contribute to interprofessional coordination and appreciation. 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Baltimore, MD: Johns Hopkins University Johns Hopkins University,mainly at Baltimore, Md. Johns Hopkins in 1867 had a group of his associates incorporated as the trustees of a university and a hospital, endowing each with $3.5 million. Daniel C. Press. Accepted: 1/00. Address correspondence to: Tammie Ronen, Bob Shapell School ofSocial Work, Tel-Aviv University, Ramat-Aviv, Tel-Aviv 69978, Israel;e-mail: tamie@post.tau.ac.il. TAMMIE RONEN is senior lecturer senior lecturern. Chiefly BritishA university teacher, especially one ranking next below a reader. , Bob Shapell School of Social Work,Tel-Aviv University, Israel. The preparation of this manuscript was supported by the HalperinFoundation. The author would like to thank Dee B. Ankonina for hereditorial assistance.