Interventions in Child and Adolescent Mental Health

• Psychology


  Aims to alleviate psychological distress and promote psychological well-being in both children and adults
• Psychology emerged as a discipline, and psychological interventions emerged as a practice


  19th century
• First psychological clinic and term "clinical psychology"


  Credited to Lightner Witmer at the University of Pennsylvania in 1896
• Lightner Witmer's clinic


  • He was a teacher who became interested in the treatment and support of children with specific learning needs and language impairment
• First clinical psychology clinics emerged in the UK (Tavistock Centre in London and Notre Dame Centre in Glasgow)


  1931
• Early UK clinical psychology clinics

  • Aimed to understand and treat difficulties with children, such as bedwetting and behavioural problems
• Clinical psychology's focus shifted from assessment to treatment, as it became apparent that behaviours could be learned and therefore unlearned


  Around the same time as Pavlov's classical conditioning theory
• Clinical psychology further emerged as a practice, due to many soldiers returning with psychological distress


  After WW2
• Clinical psychology training


  • People go through 3 years of training to become medical practitioners able to assess and treat mental health conditions and psychological distress
• First clinical psychology trainees were trained at the Maudsley Hospital in London


  1949
• Core competencies for clinical psychologists (Llewleyn and Murphy, 2014)

  • Assess
  • Formulate
  • Intervene
  • Evaluate
  • Communicate/Consult and deliver services
  • Lead
• Clinical psychologist's process


  1. Assess using validated measures, interviews, and observations

  2. Formulate using psychological theory to develop hypotheses about the individual's problems, potentially diagnosing a mental health disorder

  3. Intervene using psychological treatments and other support

  4. Evaluate the intervention to ensure the formulation is correct and the individual is improving
• Reflective scientist-practitioner model

  Clinical psychology should not be seen as purely scientific, but also reflective, using past experience and ethics alongside evidence-based practice
• Clinical psychology aims to reduce psychological distress and enhance psychological well-being through the systematic application of psychological theory and data
• Clinical psychologists aim to enable service users and carers to have the skills and abilities to cope with emotional needs and daily life, to maximise well-being
• Complex interventions


  Interventions with several interacting components, e.g. cognitive and behavioural components in CBT
• Stages for developing, evaluating, and implementing complex interventions


  1. Intervention development

  2. Feasibility and piloting

  3. Evaluation through larger trials

  4. Implementation in the real world
• Developing interventions


  • Interventions should have a meaningful effect, be based on evidence and theory, and consider implementation and feasibility
• Around 10% of children (aged 5-16) in the UK meet criteria for an emotional or behavioural disorder, with anxiety, ADHD, and disruptive behaviour disorders being the most prevalent
• For 50% of children, emotional and behavioural conditions persist 3 years later
• Prevalence rates of co-occurring conditions are higher for children with neurodevelopmental conditions like autism and intellectual disability
• Challenges in child and adolescent mental health

  • Avoiding over-diagnosis, considering behaviours in the context of child's age, and assessing children who may have difficulty communicating their feelings
• Externalising behaviours in childhood

  • Attention Deficit Hyperactivity Disorder (ADHD)
  • Oppositional Defiant Disorder (ODD)
  • Conduct Disorder (CD)
• Formulation


  Developing an understanding of what makes the person vulnerable, what triggered the problem, and what is maintaining the problem over time, in order to interrupt these sequences through treatment
• Externalising Behaviours in Childhood


  • Occur before age 12
  • Pervasive across settings so need to show high levels of inattention or hyperactivity in school or at nursery or at home
• Oppositional Defiant Disorder (ODD)


  • A pattern of angry/irritable mood and argumentative/defiant behaviour
  • Exhibited with at least one person who is not a sibling
• Conduct Disorder (CD)

  • An ongoing pattern of behaviour where the rights of others or social norms are infringed
  • Things like fire setting, theft, severe behaviours
  • Show at least three behaviours over a 12-month period
• Formulation


  • Considering what makes the person vulnerable in the first place, what triggered the problem/behaviour and what is causing the behaviour/problems to become maintained over time, what is keeping them going
  • The idea is that you can develop an understanding of the answer to all of these questions, you can try and interrupt some of these sequences within treatment
  • If you can remove factors that made them vulnerable in the first place or you disrupt factors that are allowing them to be maintained, you can reduce the problem behaviour
• Key Theories of Externalising Behaviours in Childhood

  • Parent-Child Interactions
  • Media and Peer Influences
  • Neglect
  • Cognitive factors
  • Socio-economic factors
  • Theory of mind deficits
  • Executive function deficits
  • Family environment
• There are cognitive therapies that we can develop to try and target some of these differences
• The more biological factors might not be something can be changed very easily by a clinical psychologist in intervention like structural brain differences
• Therefore, clinical psychologists tend to look more at these environmental or malleable factors
• Parenting and the Family Environment

  • Adverse familial environments and parenting practices are commonly observed in families of children who show high levels of externalising behaviour problems
  • Parents are more likely to engage in hostile parenting practices, use inconsistent discipline strategies and show less warmth in interactions
  • Child emotion regulation may mediate the relationship between parenting practices and Child Disruptive Behaviour
• Socioeconomic factors


  • Socio-economic factors play a role in the development of externalising child behaviour
  • For children who moved out of poverty, also likely to show a reduction in behavioural problems (not emotional)
  • This shows a relationship between poverty and behaviour by influencing the amount of time parents can spend time with their parents like having to work fewer jobs etc.
  • Seems to be related to the amount of time that parents can spend with their child
• Cognitive Factors


  • Executive function deficits have been implicated in externalizing behaviour problems in children
  • Impulsivity, working memory and cognitive flexibility
  • Some children with ADHD display differences in reward processing
  • Some with ADHD show preference for smaller, immediate rewards over larger later rewards and display greater sensitivity to social rewards
  • Shown in the marshmallow test, they get the choice to wait for the examiner to come back to have two marshmallows or if they call them immediately, they get one right now
  • Children with ADHD are likely to call them immediately
  • Showed greater sensitivity to social rewards, more reinforced to positive social interaction than a sticker on a reward chart
• Childhood Anxiety


  • Anxiety in children will overlap with adult anxiety
  • Children can meet the criteria for generalised anxiety disorder and the symptoms associated will be similar to what adults have. Similarly for social anxiety disorder and phobias
  • Separation anxiety is when they experience disproportionate distress when they're separated from their parents or primary caregivers
  • Behaviourally will show by following the persona round the house, not wanting to separate from them for a few minutes, don't want to sleep alone, show distress of harm coming to parents when they're separated from them
  • A combination of inherited factors and environmental stressors have been implicated in the development of anxiety in children
  • Anxiety is one of the most prevalent mental health conditions we see in children
• Traumatic Life Experiences


  • Environmental stressors a child has been exposed to that has triggered anxiety in them
  • Around 20% of children will experience a chronic physical health condition like asthma or epilepsy
  • Children with physical health conditions experience higher levels of anxiety than children without physical health conditions
  • Some psychologists argued its due to learnt helplessness due to unpredictability associated with health conditions
  • They're in hospital a lot, missing out on school, could be a stressor of it
  • A study has found an indirect effect of physical health conditions on childhood anxiety by its impacts on the family environment
  • A study by Ferro and Boyle found that physical health conditions in children can lead to higher levels of maternal depression
  • This depression or evidence of low mood in mothers can lead to family dysfunction. Mothers may be less likely to want to engage to their children or in positive interaction with their children
  • This indirect effect that physical effect can have on their parents and the wider family that can lead to anxiety and depression in childhood
  • Another effect are things like bullying or peer victimization
  • Just a couple a months after being bullied or exposed to bullying, children may show levels of anxiety of low moods
  • There are also long-term effects of bullying, high levels of bullying in childhood are more likely to meet criteria for anxiety disorders in adulthood
• Modelling and Exposure


  • Children will use information from people around them to help them learn what is safe and help them learn what is scary and dangerous
  • People with anxiety will describe having it due to seeing someone else or someone else's reaction of something the precursor for the development of their anxiety and learning from other people about what is safe and isn't an adaptive form of learning
  • Its important for children so when parents say things like "be careful around the mug its very hot" and they have a scared look if they go near the cup, it can invoke a fear response in child based on their parents fearful response which is adaptive
  • However, we know that these modelling behaviours can also be maladaptive for children as well
  • There are a number of studies who have shown that if you show children these novel animals images, you can influence their fear response to them
  • If you said "this animal is fluffy and cuddly, but this one is scary and can bite you" they're more likely to say they are fearful of the animal that is scary. Shows experimentally that you can induce a fear response in children based on what you tell them
  • If you pair the novel stimuli with faces, happy face next to animal, they show less fear etc.
• Parenting


  • Children whose parents have an anxiety disorder are at increased risk for having an anxiety disorder themselves
  • Parent anxiety can influence a number of a things about things parents do like information processing and their own parenting practises and all these things play a role in whether or not the child is likely to go onto show anxiety themselves
  • Other factors like behavioural inhibition, the amount of inhibition the child is born with is important too
  • Parents who were more overprotective to child, going to parties, social events because they're worried about their child. The child is more likely to show anxiety around going to things like parties. This is because if you don't give them the opportunity to learn they'll be okay and go out, they're more likely to be more concerned and worried about this
  • Not just an environment factor, it's a genetic factor too. Not all children who experience overprotective parenting go onto experience anxiety themselves
  • Parent child interaction is a two-way process. The way the child acts could also effect the parent. The relationship is complex and bidirectional