Topic 6: Treatment of Emotional-Internalizing Disorders {by 7/17}

There are four readings due this week for Depression and Anxiety: Mash and Barkley Chapters 4 and 5 (see specific page numbers) and Friedberg & McClure Chapters 11 and 12.  Address the following two discussion points:  (1) There are many strategies/approaches for treating anxiety in children and adolescents.  If you could only choose one strategy to be your primary focus of intervention, which would it be?  Explain.  (If you actually read parts of the anxiety chapter, this answer should be relatively obvious.)  (2) It is often reported that depression presents differently in youth compared to adults.  However, taking developmental considerations a step further, when implementing CBT interventions for depression what is one possible significant difference to consider when treating children vs. adolescents?  Your original post should be posted by the beginning of class 7/17.  Have your two replies no later than 7/19.  *Please remember to click the “reply” button when posting a reply.  This makes it easier for the reader to follow the blog postings.

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48 Comments (+add yours?)

  1. Julianna Aguilar
    Jul 12, 2014 @ 20:49:09

    According to the existing literature about treating childhood anxiety issues, exposure, modeling, and general CBT techniques have the most empirical support for producing positive treatment outcomes. Among these three, however, exposure would be the most important intervention to focus on in treatment. Exposure has two major components: in vivo exposure (i.e., the client is exposed to the actual feared stimulus) and in vitro exposure (i.e., the therapist describes the feared stimulus while the client imagines it). More specifically, exposure it typically most effective when it is implemented gradually, starting with confronting the least feared stimuli and eventually ending with confronting the most feared stimuli (i.e., graduated exposure). Research shows that there is much empirical support for the use of exposure as an effective and versatile treatment. For example, different studies show that exposure has been shown to be effective across different ages as well as races and ethnicities, has a very low dropout rate, can be effective even with minimal frequency of intervention (e.g., treatment durations have ranged from 1 day to 20 weeks), can possibly be performed by individuals with minimal training, and has been found to be superior to modeling (Mash and Barkley, 2006). Finally, the authors note that exposure is a treatment of “first resort or a component thereof” all childhood syndromes or issues pertaining to fear and anxiety (Mash and Barkley, 2006, p. 288). Therefore, though multiple different techniques and interventions have been shown to be effective for the treatment of anxiety and every case should be treated uniquely, it appears that exposure is the most useful treatment to focus on overall.

    Children and adolescents tend to experience depression differently than adults (e.g., feeling irritable instead of sad). Further, there are important differences in depression between children and adolescents as well. Two differences that I found particularly important are the rates and expression of suicidal ideation, and differences in abstract reasoning. First, adolescents with MDD are more likely than children with MDD to have suicidal ideation and a history of suicide attempts. However, it is also important to note that adolescents and children may express their suicidal ideation differently. Mash and Barkley (2006) note that children may display their preoccupation with death and suicide more through play as opposed to verbal reports. Therefore, it is particularly important to notice play themes that could alert the therapist to possible suicidal ideation in children, especially if that child is not at a developmental stage to be able to verbally express those thoughts and concerns. Second, the authors point out that there seem to be important differences in the causes and maintenance of depression between children and adolescents. Children, unlike adolescents, may lack the ability to engage in abstract reasoning and formal operational thinking associated with the stable explanatory style of depression. Instead, negative life events have been shown to be a significant predictor of depression in children. Therefore, it has been suggested that environmental factors contribute more to depression in children as opposed to cognitive factors that have more influence on adolescent depression. Overall, it is important to consider the children or adolescents’ developmental level when conceptualizing their case and implementing appropriate treatments for their specific depressive symptoms.

    Reply

    • Ashley
      Jul 13, 2014 @ 20:03:17

      Julianna, you talk about abstract reasoning as one of your considerations when treating children vs. adolescence. Since the other consideration you had was suicidal ideation I was curious to know if you thought abstract reasoning abilities played a direct roll in the ability to be preoccupied with death? Do younger children lack the presentation of suicidal ideation due to their age and mental capabilities?

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      • Julianna Aguilar
        Jul 18, 2014 @ 11:06:58

        Ashley, that is a good question about how abstract reasoning influences suicidal ideation. To me, it seems like any sort of preoccupation with death is a complex process that presents itself differently depending on age and developmental level. For example, adolescents are able to engage in abstract reasoning and understand death and suicide in more sophisticated ways (e.g., reasoning about death’s permanency and verbally expressing those thoughts). To answer your question, I do not think that children lack the presentation of suicidal ideation because of less developed cognitive abilities, I think instead that it is a different presentation. For example, the texts pointed out that suicidal ideation or thoughts about death may be displayed through play with children. For that reason, I think it is important to consider the client’s age and developmental level in order to be aware of he or she may express themselves in different ways.

        Reply

    • Sarah Chelio
      Jul 16, 2014 @ 11:26:57

      Julianna,

      I agree with your point on considering developmental level when it comes to depression in youth. I had not realized just how differently children and adolescents express their symptoms prior to doing these readings. I think that looking at play for suicidal expression in children is a good idea because that is one of the only ways they can express their thoughts. I think that if there is a constant theme of suicide in a child’s play this should be examined carefully and dealt with.

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    • Juliana Eells
      Jul 19, 2014 @ 15:29:05

      Julianna,
      I believe it was in my undergrad childhood development class when the professor explained that children begin to really understand death and the finality of death around age 9. I wonder if this development in understanding the concept of death has an influence on the increased rates of suicidal ideation and suicide attempts in adolescents. If a younger child does not fully understand the concept of death, they may be less likely to become preoccupied by suicidal thoughts.

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    • Anthony Rofino
      Jul 20, 2014 @ 08:43:35

      Julianna, as someone who works with children, I found it really interesting the part about you mentioning that you must focus on children’s play to identify suicidal ideation. This is not something I knew before this reading and it is important to look into that when assessing a child. It is something I will try to keep a more watchful eye out for. However, I am curious how often this is seen in children, as suicidal tendencies seems uncommon at that age.

      Reply

  2. Ashley
    Jul 13, 2014 @ 19:59:31

    1). If I could only choose one strategy for treating anxiety it would be exposure therapy. Although the book as a beautiful chart of all possible treatments leading up to exposure, I think exposure is the most important. There is nothing like getting over a fear by experiencing it. Exposure should be done in a graduated manner and as realistic as possible. There are two types of exposure, in vitro exposure and in vivo exposure. In vitro is when the client and therapist talk about and vividly describe the feared stimulus and in vitro is when the client experiences the feared stimulus. By taking a client through exposure not only can the therapist and client talk about the impracticality of the fear but the client can first hand see how the fear is unrealistic. It allows for personal growth and the ability to over come the fear. Words can only take you so far, by experiencing the feared situation, clients can more readily overcome anxiety.
    2). In consideration for treating children vs. adolescents I found that suicidal ideation was the biggest concern to consider when working with adolescents. Both Mash & Barkley and Friedberg & McClure discuss how suicidal ideation/attempts is higher among adolescents. Friedberg states that statistics from 1999 found that suicide was the 3rd leading cause of death for adolescence. Barkley talks about how children display depression through crying, temper tantrums and behavioral problems where adolescence are more likely to consider/attempt suicide. According to the “Center for Disease Control and Prevention: Violence Prevention” (2014) between the ages of 10 and 24 4,600 lives are lost each year due to suicide and 157,000 adolescents ages 10-24 are seen in the emergency room for self-injurious behaviors. Of the attempted/completed suicides 81% are male and 19% are female. According the to National Institute of Mental Health suicide rates in the US have gradually increased since 1999 to over 12% of the population (of 100,000 people who commit suicide a year –just to put into perspective how many are adolescents). It is clear that when treating adolescents, suicide ideation, planning or action should be assessed for regularly.

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    • Sarah Chelio
      Jul 16, 2014 @ 11:34:07

      Ashley, I agree with suicidal ideation being a significant difference in expression of depression in children vs. adolescents. Furthermore, I found the statistics you mentioned from the statistics you mentioned to be alarming. The large number of adolescents taking their own lives points to the importance of mental health professionals to be aware of warning signs. We need to be educated on what suicidal ideation looks like, as well as know the differences in presentation between children, adolescents, and adults.

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    • Taylor Tagg
      Jul 16, 2014 @ 22:23:09

      Ashley, I liked how you emphasized the importance of talking about the impracticality of the fears and anxieties and realizing how such fears and anxieties are unrealistic through use of exposure. By doing so, you essentially highlighted how exposure in itself can simultaneously include cognitive restructuring and decatastrophizing. By facing fears through exposure, youth will undergo a change in thought process, even if it is not the main intervention of treatment. I also liked how you called attention to the statistics of suicide ideation/attempts in children versus adolescents. I think it is important for us to remember that when treating depression, pharmacotherapy may also be more prevalent in adolescents and such a treatment modality has also been associated with an increase in suicidal thoughts and behaviors.

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    • Nafi
      Jul 18, 2014 @ 18:56:48

      Ashley, I agree with your thoughts on exposure therapy that experiencing something in the moment is the only way to get over a fear. It’s one thing to talk about it in therapy and discuss the skills and strategies to implement but sometimes in the moment all that goes away. This goes for many other things as well, and with exposure the client can “practice” putting their skills to work in the moment. Moreover, the present of the therapist can also be helpful in reviewing the experience afterwards and discussing the process for the client.

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    • Rebecca Boisvert
      Jul 19, 2014 @ 06:07:43

      Ashley, I think that your description of exposure therapy is excellent, but in a text book, and in a therapeutic sense. The explanation is academic in that the major points of the technique are reviewed, yet it is clear, concise, and to the point. Using these words to explain the technique to a client should allow them to fully grasp the concept without becoming overwhelmed with the technicality of the process. I especially like how you included the aspect about personal growth, as this is the end goal, yet the part that may often be forgotten when “picking apart” the frameworks of the therapy itself.

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  3. Sarah Chelio
    Jul 15, 2014 @ 15:43:16

    1) If I were to choose only one strategy for treating anxiety in childhood or adolescence, it would be exposure therapy. Although interventions such as self-monitoring and relaxation seem to be useful and have strong empirical support to back them up, they seem to just be leading up to exposure. This allows children to fully participate in their treatment. It gives them a chance to face anxiety-provoking situations safely in therapy before encountering them in real life. Since this can be challenging and frightening, exposure is done gradually. It can be done by having the therapist describe feared situations and establishing a discussion (in vitro) or actually exposing the child to the actual stimuli (in vivo). Research shows that in vivo is the most effective, but for more severe cases this should not be introduced right away. Each child is different, so how gradually exposure is introduced depends on their level of anxiety.

    2) Youth with depression present differently than adolescents. One significant difference I found was that adolescents rate higher in feelings of hopelessness. Mash & Barkley suggest that this is due to higher cognitive development. Children endorse hopelessness less frequently because they are not yet capable of generalizing and forming concepts at this level. One other difference I found was in how depression effects academics. Both populations often suffer in their schoolwork as a result of the disorder, but as children get older this may be more severe. Young children are likely to miss school or not complete their work, but adolescents have the ability to drop out of school entirely, and often do.

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    • Nafi
      Jul 18, 2014 @ 19:03:38

      Sarah, I agree with your thoughts on depression in children and adolescents. It is a serious disorder during these years and can be seen carrying well into adulthood with some clients. I appreciated your thoughts on depression in academia as you are right that with adolescents it can become more severe as they can drop out of school. Also as we all know that depression can present differently in different people, would the academic figures at the school or even that adolescents parents consider depression as the contributing factor to this youth dropping out of school? Probably not and this youth would just continue to go on mismanaging his/her symptoms. I am not sure how much education on mental health i provided for teachers in their training but it would be helpful of these professionals could also recognize the signs of disorders such as depression in children/adolescents.

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  4. Sara Grzejszczak
    Jul 16, 2014 @ 07:51:02

    If I could only choose one strategy to be my primary focus of intervention it would be exposure therapy. Exposure therapy does come with a second part, relaxation training. This two part process is important because exposure therapy has been shown to be effective but a child cannot face their fears without having some type of coping mechanism, such as muscle relaxation or systematic breathing techniques. Once children have the relaxation part exposure should be introduced. Both in vitro exposure (or exposure which is imaginal and has the therapist describing a scene that involves the stimulus the child fears or is anxious about) and in vivo exposure (or exposure which is direct confrontation with the stimulus that the child fears or is anxious about) are important to introduce to children and have children participate in. Sometimes creating in vivo exposure may be difficult depending on the setting of therapy but therapists are encouraged to do the best that they can. It is also important to remember that exposure is gradual and so in vitro exposure can be used to start with while trying to come up with a realistic in vivo exposure situation, unless a real situation can be carried out for in vivo exposure.

    A significant difference to consider when treating children and adolescents who have been diagnosed with depression is that children tend to not vocalize their emotional state and instead complain about somatic symptoms where adolescents are more able to verbalize their symptoms. This is important to consider because children may not have the ability to verbalize their distress and so therapists have to learn and understand their creative language and really look at their somatic complaints. Children who keep vocalizing somatic complaints may also repeatedly go visit the nurse or have their parents take them to the doctor and miss school because of the somatic complaints. Adolescents, who can verbalize their symptoms, help clinicians because they can more readily identify symptoms that they are currently having.

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    • Taylor Tagg
      Jul 16, 2014 @ 22:30:55

      Sara, I really liked how you included the relaxation training component to exposure therapy. How would we expect a fear-stricken child to come face to face with whatever the stimuli or situation is, without having the ability to cope with it? We would most likely be setting the child up for failure and possibly cause even further harm associated with his or her fear and anxiety. I also liked how you discussed the somatic component of depression in children versus adolescents. This opened my eyes a little because I feel as though more often than not, somatic complaints are associated more with anxiety-like features as opposed to depression. Therefore, I am glad that you brought up this point.

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    • Larrisa Palmer
      Jul 19, 2014 @ 01:48:47

      You mentioned a very important component (relaxation training) of exposure therapy that I never really focused on. It is important that we teach our clients ways to relax or cope before embarking on exposing them to the objects or things they fear.

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  5. Angela Vizzo
    Jul 16, 2014 @ 16:14:33

    If I could only choose one strategy to ure when treating anxious children and adolescents it would be exposure therapy. Exposure therapy can be done through imagining an anxiety provoking situation, also called in vitro exposure or through direct, in vivo, expose where the person is directly confronted by the anxiety provoking situation or stimulus. When working with anxious clients it is best to develop an anxiety hierarchy and work up to the most anxiety provoking stimuli. Exposure therapy has been proven to be the most effective treatment for anxiety disorders.

    One significant difference is suicidality and suicidal ideation is more prevalent in depressed youth versus depressed adults. This is important to focus on as a hopeless, depressed youth has a harder time than an adult seeing past the present and viewing the big picture. Because of this they may see suicide as the only option to “feel better” when that is not the case. Youth are also more impulsive than adults so suicidality should be assessed and a plan should be put in place immediately.

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    • Sara Grzejszczak
      Jul 17, 2014 @ 15:39:30

      Angela, I like how you mentioning using a hierarchy of stimuli that case anxiety and start exposure with the lowest level item and work up to the highest. If therapists did not construct a hierarchy therapy may not be as effective because the children did not learn how to cope with the stimulus that causes the least amount of anxiety let alone the most! I also like how you mentioned that youngsters view suicide as a solution to problems that are most likely temporary and that they are more impulsive. I feel that many times we, as adults, do not remember how impulsive children are and we have to be very cognizant of this fact.

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  6. Taylor Tagg
    Jul 16, 2014 @ 22:10:02

    1) Many strategies and/or approaches have been proposed in regards to the treatment of anxiety in children and adolescents. Exposure, either through in vivo or imaginal, would be my treatment of choice when working with anxious youth. I would choose an exposure-based approach not only based on the empirical findings supporting it, but also because of my own therapeutic beliefs about exposure. Avoidance is the key factor in the maintenance of anxiety. While techniques such as modeling, cognitive restructuring, and systematic desensitization may prove to be beneficial in treatment, they would most likely be insufficient without the implementation of exposure techniques. I also believe in the importance of establishing exposure-based hierarchies, as they facilitate in targeting specific fears and anxieties, and essentially set the stage for therapeutic goals in eliminating such fears and anxieties. With that being said, while other therapeutic approaches, such as cognitive restructuring and modeling, can be incorporated in the treatment of anxiety in youth, treatment effectiveness would be most high through additional (and central) use of exposure techniques.

    2) Depression generally presents differently in youths in comparison to adults. Taking developmental considerations a step further, when implementing CBT interventions for depression, one possible significant difference to consider when treating children vs. adolescents would be in regards to irritability and aggression. According to Mash and Barkley (2006), children typically do not experience prolonged mood disturbances and experience a variation in moods from day to day (i.e. irritability broken up by shifts of positive mood). More so, due to limits on verbal and cognitive abilities, children (compared to adolescents) may find it difficult to express distress head on and therefore may engage in aggressive tendencies. The emergence of irritable and aggressive responses in childhood depression has been a topic that I have personally been interested in, since it is something that I have seen throughout my clinical work- sometimes when a child presents as angry, mad, and irritable, it is not so much the child feeling angry, but rather the child feeling distressed about whatever is going on (i.e. parents, school, peers, bullying) and not being able to appropriately express and manage the accompanying feelings.

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    • Robert
      Jul 19, 2014 @ 14:19:31

      That’s a good point you made, Taylor, about how children’s symptoms of depression differ from adults and adolescents. I have also observed how depressed children become frustrated with their inability to effectively address their sources of distress and can feel angry or irritable because of this. This pattern and the variability in daily mood can make it harder for adults to pick up signs of depression in children versus adults and adolescents.

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    • Robin Horsefield
      Jul 19, 2014 @ 22:11:07

      Taylor, I was thinking about your comments on aggression and its prevalence in children with depression. Previously I would have thought that younger children would withdraw and adolescents would be the children that would present with more aggression, but it sounds like I would experience something different in clinical practice.

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  7. Rebekah Kiely
    Jul 17, 2014 @ 09:26:20

    Of the various ways in which one could approach treating anxiety in children and adolescents I find that employing exposure techniques would be most beneficial. When treating anxiety in children and adolescents, the use of gradual exposure techniques and the employment of an anxiety hierarchy, as created together with the child or adolescent is extremely important. Based on the rankings of what is presented in this hierarchy, exposure to each anxiety provoking stimuli functions on a continuum. That is, exposure is presented from gradual to intense and imaginal to in-vivo. The use of systematic desensitization is also relevant. A child’s anxiety is a learned response; feelings of anxiety have been conditioned to certain stimuli. As such, using counterconditioning and pairing an aversive stimulus with the feelings of anxiety will help the child learn a new response to the previously anxiety eliciting stimulus.
    When considering CBT for depression in children vs. adolescents one possible difference that should be addressed is the increasing importance of peer relationships as children enter into adolescence. Although peer relationships and social interactions are important for younger children too, it is during adolescents that the stresses of peer relationships come into significant play. The way in which many adolescents may appraise their self-worth on social means, will make CBT interventions for depression differ from younger children. When dealing with a depressed adolescent vs. a depressed child, the adolescent’s peer relations may need to be emphasized more than the child’s.

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    • Ashley
      Jul 17, 2014 @ 11:02:24

      Rebekah, I liked how you chose peer relationships to focus on. I had not considered that when addressing adolescents but agree with you when you say that they become a huge factor in adolescents behaviors and emotions. I think addressing social relationships can actually lead to a happier and healthier life.

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    • Juliana Eells
      Jul 19, 2014 @ 15:46:38

      Rebekah, I had not considered the difference in social lives between adolescents and younger children either. Now that I think about it, I can see how socializing with peers would be much more important with many adolescents. Some adolescents can become so focused on socializing that it can seem like the most important thing in life, so it may be even more upsetting to an adolescent when they are struggling in that area.

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  8. Larrisa Palmer
    Jul 17, 2014 @ 11:29:53

    1. There are several strategies for treating anxiety in children and adolescents. One strategy that I would choose is exposure therapy. Exposure therapy is an important intervention tool for almost all anxiety disorders. With exposure therapy, therapists can guide children and adolescents to confront their feared stimuli in a therapeutic manner. Feared stimuli can be presented in an imaginary way or ‘in vivo,’ which is exposure to real life situations. A lot of children may not be able to comprehend components of cognitive restructuring, so I would choose exposure because they can see and experience it first-hand.
    2. Depression can take many different forms and often presents itself differently in youth and adults. However, some differences have also been identified between children and adolescents, one difference I would consider is somatic complains. Although both children and adolescents may complain of somatic pain, adolescents are usually better able to communicate their symptoms.Depression in younger children is often more challenging to identify because they are unable to verbalize as effectively, but rather they present through behavioral cues. It is often identified by complaints such as headaches, stomach aches or other physical complains.

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    • Jane Jenkins
      Jul 17, 2014 @ 14:35:32

      I had not considered the somatic symptoms in children versus adolescents so I’m glad that you wrote about it. Many of us think more about the cognitive differences and less about the way they express their symptoms. Thanks for reminding me that this is very important as well.

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    • Rebekah Kiely
      Jul 19, 2014 @ 13:39:46

      Larrisa,
      I like the point you made about the challenges relative to somatic symptoms in children vs. adolescents. I think being able to effectively communicate is one of the biggest difficulties when it comes to treating younger children. This also emphasizes the importance of psychoeducation and making emotion identification a goal for such individuals I believe.

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  9. Anthon Rofino
    Jul 17, 2014 @ 12:10:38

    1) While there are many strategies mentioned in the reading for treating anxiety in children, exposure therapy seems to be the most important one to use. With exposure therapy, it allows the client to approach head on what is making them anxious and to handle it with the help of the therapist. This can be done in vivo, through role plays, and other various methods to achieve the best result for the client. Cognitive restructuring may be difficult for some children, so exposure therapy seems the strongest method.
    2) Two things to consider when working with depression in children compared to adults can be applied to young children and adolescents. With children, it is important to note that they display depression differently from adults. Where, instead of describing their mood like an adult can, Children can display depression through temper tantrums, crying, and behavioral issues. Also, children have been known to show suicidal ideation through play, so it is important to monitor their play. Adolescents are also more at risk for suicide compared to adults. While female adolescents are more likely to attempt suicide, male adolescents are more likely to succeed in their attempts. It is important, more so with adolescents than adults, to monitor for suicidal ideation, as the risk is much higher with this age group.

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    • Angela Vizzo
      Jul 17, 2014 @ 20:43:00

      Anthony, I agree with your comment that it is important to realize that children display their depression differently than adults. I think a lot of time depression can be overlooked in children and attributed to a different problem rather than what it actually is because of the different way they present. In addition, especially with parents who may not be aware of this different presentation, they may not even realize their child is depressed and needs help.

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    • Rebecca Boisvert
      Jul 19, 2014 @ 06:14:35

      Anthony, I think that your comment about children modeling SI through play is very valuable in the context of depression presentation. It is important to remember that most children are unable to vocalize their feelings with their words. Because of this, they must use alternate methods of emotion expression (such as play or tantrums) to let others know how they are feeling. While this may be frustrating, it is also an incredible source of data regarding the child’s psychological state, and should definitely be used when determining their needs.

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  10. Robin Horsefield
    Jul 17, 2014 @ 12:30:16

    The trouble with treating anxiety is that anxiety is a normal part of everyday life. Therefore treating anxiety must be reserved for those whose anxiety exceeds “normal” or expected amounts. Exposure treatment is the most supported intervention there is for treating anxiety disorders. The most helpful aspect of exposure is its adaptability; the types and levels of exposure can be modified for any age and any anxiety source. There are also two types of exposure, in vitro and in vivo. In vitro exposure includes imagining that you are confronted with your source of anxiety and in vivo includes direct contact with your feared stimulus. The basic understanding of exposure is that it provides evidence against our most ingrained anxious thoughts. How can I be afraid that I am going to die from germ exposure if I touch doorhandles when I have touched twenty door handles and nothing happened. The mind cannot hold two opposing views at the same time and therefore must choose.

    There are a number of differences between treating children and adolescents with depression. Children still live in the world of fantasy and play. Adolescents have often just come out of this world and are trying to prove themselves how “adult” they are. Adolescents are also dealing with an influx of hormonal changes that may present as depressed symptoms. When choosing CBT interventions to help treat these depressed kids therapists have to keep in mind that there are significant differences in how these children talk about their problems. The Friedburg chapter discusses in length that adolescents and children talk about suicide very differently. Adolescents are more likely to come out and say “I just want to die” directly, whereas younger children verbalize this thought in different ways such as “I wish a car would hit me.” These differences may be easy to miss or misunderstand if a therapist is not aware that they exist and this could lead to disastrous oversights.

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    • Rebekah Kiely
      Jul 19, 2014 @ 13:40:09

      Robin,
      Your statements about the difference in how suicidal ideation will present with children vs. adolescents is very interesting. I agree completely and it also makes me think about the importance of careful observation when it comes to children’s behavior and play. Younger children’s limited abilities to effectively communicate will make it difficult to understand all the factors underlying suicidal ideation and depression. However, the themes, events, thoughts, or feelings that a child may communicate through his/her style of play can support effective identification of exactly what interventions need to occur.

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  11. Melysa Faria
    Jul 17, 2014 @ 12:41:59

    1.) Although there are many different treatment options available for children with anxiety, if I had to choose one strategy as the primary focus of intervention for a child with anxiety, it would be exposure therapy. Exposure therapy allows children to use previously learned coping skills (i.e. deep breathing, meditation, etc.) to gradually confront anxiety provoking stimuli in either an ‘in vivo’ (real life) or imaginary scenario. As children are given the opportunity to work up to facing the antecedent to their anxiety, avoidant behaviors are reduced and the child is able to safely experience anxiety provoking stimuli without experiencing any negative consequences that would reinforce feelings of anxiety. Exposure hierarchies can be created to rank anxiety provoking stimuli from ‘least amount of anxiety’ to ‘greatest amount of anxiety’ in order for the child to gradually work on confronting these stimuli. Using imaginary scenarios of antecedents to anxiety and working up to ‘in vivo’ exposure is another way to gradually work on exposure with children. ‘In vivo’ exposure is a useful learning experience and provides the opportunity for practicing coping skills to be generalized in real life situations outside of therapeutic intervention.

    2.) When working with youth with depressive disorders, it is important to keep the developmental stage of the client in mind in order to appropriately plan interventions. Youth often present different symptoms of depression than most adults. Younger children especially may present with more somatic symptoms, irritable mood and acting out behaviors. Depending on the age of the youth, he or she may not have the ability to cognitively process and verbally express feelings and thoughts related to depression. Therefore, they are more likely to act out or exhibit physical symptoms. When working with adolescent youth with depressive disorders, irritability and acting out behaviors may still be present, however cognitive processes and verbal communication of emotions and thoughts are much more common. Suicidal ideation is a common theme among adolescents with depression, so it is very important to assess for any suicidal thoughts, self-injurious behaviors, or history of suicidal ideation, gestures and/or attempts.

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  12. Paige Hartmann
    Jul 17, 2014 @ 13:07:56

    Although there are many approaches for treating anxiety in children and adolescents, if I could only choose one intervention it would be exposure therapy. Exposure therapy allows the client to play an active role in their treatment for anxiety. Exposure is implemented in a gradual manner, starting with in vitro (having the therapist describe the feared situation) and working towards in vivo (exposing the client to the feared stimulus). Through exposure therapy, the client is able to deal with their anxiety in a safe environment with the therapist and gradually work up to facing their anxiety.

    One significant difference to consider when treating depression in children vs. adolescents is how the symptoms of depression are presented. Typically children who are depressed tend to act out or have somatic complaints since they are not able to verbally express what they are feeling. Adolescents on the other hand, are generally more cognitively aware of their depressive symptoms and are able to communicate this more effectively.

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    • Sara Grzejszczak
      Jul 17, 2014 @ 15:46:57

      Paige, I like how you mention that children have many somatic complaints when they have symptoms of depression. It is important for us as therapists to remember that many times children who have somatic complaints do not necessarily have a physical problem that needs to be medically treated. Instead their headache or stomachache is due to depressive symptoms and feelings of sadness and hopelessness.

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    • Larrisa Palmer
      Jul 19, 2014 @ 01:40:14

      For the most part, a lot of us are on the same page with exposure therapy as an intervention for treating children and adolescents with anxiety. I do agree with you that exposure therapy allows the child to take an active part in treatment. I believe that a child is better able to grasp information presented to him or her when he or she can see and touch it and exposure therapy offers that.

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  13. Juliana Eells
    Jul 17, 2014 @ 13:50:57

    The strategy of primary focus for intervention in treating anxiety in children and adolescents would be exposure. Friedberg & McClure describe how it is necessary for children and adolescents to directly face their fears and anxieties while learning coping skills for how to deal with their anxiety. With children and adolescents, simply talking about their anxiety is not enough to change the anxiety. It would be important to incorporate exposure through a systematic desensitization plan while also coaching and modeling new skills that the child can use to cope with the anxiety. Some of these coping skills may include self-monitoring, self-talk, relaxation techniques, etc.

    One significant difference in treating depression in children vs. adolescents might be the types of interventions that you would be able to use. Adolescents are more cognitively advanced and more mature, and therefore may be able to participate in more complex cognitive interventions than younger children could. With younger children you may have to rely more on behavioral techniques such as activity scheduling and social skills training. Adolescents may be able to engage in cognitive restructuring techniques more, especially older adolescents.

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    • Jane Jenkins
      Jul 17, 2014 @ 14:33:12

      Juliana, your comment that focuses on the need for active participation with kids versus just talking with them is a very good point. As we have learned, children learn best through experience and that is what should be focused on if we intend to be effective in helping them.

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  14. Jane Jenkins
    Jul 17, 2014 @ 14:30:19

    1) If I could only choose one strategy as a primary focus of intervention, I would use gradual exposure. Gradual exposure helps a child or adolescent face his or fears in an experiential way, and in a supportive environment. This is the best evidence-based practice, and the one that makes the most sense. This is especially true if one looks at fear and anxiety as part of the human experience (Mash & Barkley, p 279). This idea considers fear and anxiety to be common experiences for children during development. The only differences between clinical and non-clinical anxiety then, is that some kids need help getting through it. Perhaps, then we could look at gradual exposure as a way to provide a safety net for kids with high anxiety sensitivity, who experience higher occurrences of anxiety disorders.
    2) One significant difference to consider when treating children vs. adolescents for depression is the degree to which the child is involved in the abstract areas of the treatment. Younger children are taught to engage in more fun activities to improve their negative thinking, but they do not have the cognitive ability to understand the abstract process of identifying cognitive distortions, discounting them, and then reframing them. Adolescents are more active participants in their own treatment and are able, and expected to help identify problems, understand the rationale behind the treatment, and take a role in attacking the problems. They can also comprehend feedback about symptom changes.

    Reply

    • Angela Vizzo
      Jul 17, 2014 @ 20:48:27

      Jane, I like your comments on anxiety and fear and how those emotions are experienced by all children, not just those with an anxiety disorder. I think it is important to make them aware of this so they know that it is normal to feel the way, they are feeling, just maybe not as frequently as they, themselves are experiencing that emotion.

      Reply

  15. Melissa Symolon
    Jul 17, 2014 @ 14:33:08

    Based on the reading and experiences from classes, I think exposure therapy is the best and most useful intervention for anxiety. It is one thing to talk about and process your fears, but it entirely different to face them head on. Physically exposing people to their feared stimuli gives them a sense of confidence and safety they cannot feel just be processing their fears. Generally, exposure is gradual and starts off with low-feared stimuli and progresses. But coincidentally during supervision at internship this week, my supervisor told me about a program developed by someone who spoke at the Beck Institute in the past who exposes participants to their highest fear first. It turns out these people, while terrified at first, are extremely motivated to engage in other exposure activities after accomplishing the worse and first one. I, personally just thought this was an interesting program because I’ve never heard of that technique before and thought it was interesting what a positive response that researcher/professional received.

    I think the main difference between using CBT to treat depression in children and adolescents, and one we talk about a lot in class, is that treatment interventions need to be more behaviorally-focused for younger children because they lack cognitive skills and abilities that adolescents have. This is important because younger children typically have a hard time or are unable to identify automatic thoughts or recall emotions, physical sensations, and thoughts unless they are in the moment. Adolescents have developed more and are able to identify automatic thoughts and alter or dispute those thoughts once they are identified. Once they do that, they are able to engage in more behavioral experiments, etc.

    Reply

    • Julianna Aguilar
      Jul 18, 2014 @ 12:20:53

      Melissa, the exposure program you shared about sounds interesting. I am intrigued about how it actually works especially given our conversation in class yesterday about new research regarding how best to implement exposure. My initial reaction to reading your post was that facing the client’s highest fear first sounds very similar to flooding which has shown not to be very effective. However, I wonder if there are procedural differences that make the technique you mentioned more effective than flooding. It also sounds like it could be similar to what Dr. V. mentioned in class regarding creating a hierarchy of feared stimuli and facing those stimuli in a somewhat random order as opposed to working from the least feared to the most feared. What you said certainly makes sense, though, about the feelings of accomplishment and confidence instilled in the client for overcoming the most feared stimuli first.

      Reply

    • Anthony Rofino
      Jul 20, 2014 @ 08:45:33

      Melissa, I like that you talk about not focusing on children trying to assess automatic thoughts and going for more behavioral skills. I understand that the hope is that you curb the behaviors, the mentality will follow. I am curious as to how effective this technique is for children, or if it is better to treat solely with medication.

      Reply

  16. Becca Boisvert
    Jul 17, 2014 @ 14:44:58

    If I was only able to choose one intervention method for the treatment of anxiety in children and adolescents, it would be exposure. The technique of exposure allows for several methods of intervention which can begin with a relatively mild/non-invasive imaginal procedure in this the individual visualizes the stressful situation and approaches the stimuli without actually coming into contact with it (termed in vitro exposure). Then, if the individual becomes more comfortable with the situation, they may be ready to approach the stimulus, and face the stressful situation directly (termed in vivo exposure). The latter method is certainly more invasive and would produce more stress, however both techniques have been found to effectively reduce levels of anxiety over time. Essentially the individual learns to “face their fears,” and gradually, over a period of time, the stress that the stimulus caused initially is reduced because of repeated exposure until it becomes neutral.
    When considering childhood and adolescent depression, the text notes that the fundamental components of the disorder are similar to adult depression. However, modifications should be made in diagnosis and treatment to reflect developmental considerations for both children and adolescents. Children are more likely to experience mood irritability than the typical dysphoric symptom of adults. When considering adolescents, the presentation of hopelessness is a unique symptom that is thought that younger children may not be capable of having. This is believed to be because adolescents have developed more cognitively, and can perceive situations in an all-encompassing/generalizing manner. Along similar lines, adolescents are more likely to experience feelings of suicidality than children when depressed. This should be a primary concern when treating adolescents who are experiencing depression

    Reply

    • Melysa Faria
      Jul 19, 2014 @ 22:18:33

      Becca,
      It seems like exposure therapy is the popular choice among the class as a treatment for anxiety disorders. The way you described exposure therapy in your post was very detailed, and I like the way you explained how this type of therapy would be used as a step by step process, gradually decreasing anxiety. I feel that when explaining exposure therapy to a client, explaining it in this manner would make the client have a sense of ease and comfort in knowing that exposure therapy does not need to involve immediate direct exposure. This could help to decrease their anxiety around the process of therapy and understand gradual exposure.

      Reply

  17. Nafi
    Jul 17, 2014 @ 15:21:59

    In treating anxiety in children and/or adolescents, the technique that I would implement as an intervention would be exposure. A great intervention when used correctly, exposure is the best way to give client’s a chance to practice skills learned in therapy. Depending on the client, assessing which form of exposure is important, especially depending on the time frame which the technique is being employed. For some children/adolescents, after 3 months of weekly session they may be ready for imagery exposure while for another client, they may need 6 months of weekly sessions before this intervention is introduced. Another good thing about this technique is the use of an anxiety hierarchy to assess varying levels of anxiety at different moments. Helping children/adolescents to confront their anxiety provoking stimulus/stimuli will in the long run be more beneficial. Working with client’s we know that homework assignments to practice skills are home may not be getting done effectively, and the client may be able to execute the skills in therapy but what about in the moment of anxiety. Can the child/adolescent employ deep breathing or counting techniques when faced with a real life situation? Through exposure, the client is given a chance (s) to employ treatment in the moment.

    Working with depressed children/adolescents, symptoms will present differently than in adults. Being able to assess and identify symptoms is important as depression presents differently in all people. With children/adolescents, symptoms such as irritability are more present rather than symptoms of sadness as seen with adults. With adolescents, suicidal ideation should be watched closely as it may present differently than in children. Furthermore, assessing an adolescence’s impulsivity is important as he/she may never verbalize SI but may be displaying some subtle signs. Children on the other hand may display these feelings through play or artwork and should be watched carefully. Keeping in mind the client’s developmental level is always important for developing treatment goals and intervention.

    Reply

    • Robin Horsefield
      Jul 19, 2014 @ 22:12:00

      I can see that we all agree that exposure is the chosen intervention, but I like that you mentioned that there can be such lengthy time frames for when it should be introduced. It makes sense that different children may need more prep time in sessions, building their confidence before the therapist can introduce exposure. I agree as well that the hierarchy can be useful (especially when we discussed the “jumping around” element in class).

      Reply

    • Melysa Faria
      Jul 19, 2014 @ 22:26:34

      Nafi,
      I like the way you highlight the importance if the use of homework assignments to enhance the generalization of skills outside of therapy, particularly with exposure therapy. When practicing ‘in vivo’ exposure, the client would be most likely completing these experiences outside of therapy and in a real world setting. Not following through with homework assignments like this would make therapy for anxiety ineffective. In order for the treatment to work, the client must be dedicated to working on goals inside and outside of therapy.

      Reply

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Adam M. Volungis, PhD, LMHC

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