Introduction to Abnormal Child and Adolescent Psychology. Robert Weis
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mental health treatments are not available in many communities. For example, multisystemic therapy is an effective treatment for older adolescents with serious conduct problems. Many well-designed studies have shown multisystemic therapy to reduce adolescents’ disruptive behavior problems, improve their social and academic functioning, reduce their likelihood of arrest and incarceration, and save the community money (Dopp, Borduin, Wagner, & Sawyer, 2014; van der Stouwe, Asscher, Stams, Deković, & van der Laan, 2014). However, few clinicians are trained in providing multisystemic therapy, and it is available in only a small number of communities.
Third, there are simply not enough experts in child and adolescent mental health to satisfy the need for services. Our current mental health system is able to address the needs of only about 10% of all youths with psychological problems. Furthermore, only 63% of counties in the United States have a mental health clinic that provides treatment for children and adolescents (Cummings, Wen, & Druss, 2013). Youths who receive treatment are typically those who show the most serious distress or impairment. Youths with less severe problems, such as moderate depression, mild learning disabilities, or unhealthy eating habits, often remain unrecognized and untreated until their condition worsens. Inadequate mental health services are especially pronounced in disadvantaged communities.
Finally, stigma can interfere with children’s access to mental health treatment (O’Driscoll, Heary, Hennessy, & McKeague, 2012). Stigma refers to negative beliefs about individuals with mental disorders that can lead to fear, avoidance, and discrimination by others or shame and low self-worth in oneself (Corrigan, Bink, Schmidt, Jones, & Rüsch, 2016). Stigmatization of mental illness comes in many forms. During casual conversation, people use terms like crazy, wacked, nuts, and psycho without giving much thought to the implications these words have for people with mental health problems. Children may use the derogatory term retard to tease their classmates. Parents of children with psychological disorders often report discrimination from school and medical personnel because of their child’s illness. Some insurance companies discriminate against individuals with mental disorders by not providing equal coverage for mental and physical illnesses. Movies and television shows unfairly depict people with mental health problems as violent, unpredictable, deranged, or devious. Even children with mental disorders are portrayed in a negative light (Martinez & Hinshaw, 2016).
Some parents are reluctant to refer their children for therapy because of the negative connotations associated with diagnosis and treatment. In fact, roughly 25% of all pediatrician visits involve behavioral or emotional problems that could be better addressed by mental health professionals (Horwitz et al., 2002). Parents often seek help from pediatricians and family physicians to avoid the stigma of mental health treatment. Stigma associated with the diagnosis and treatment of childhood disorders causes many at-risk youths to receive less-than-optimal care (Bowers, Manion, Papadopoulos, & Gauvreau, 2013).
Stigma can also negatively affect youths and their families in several ways. First, it can cause a sense of shame or degradation that decreases self-esteem and lowers self-worth. The negative self-image generated by the social judgments of others, in turn, can exacerbate symptoms or hinder progress in therapy. Second, stigma can lead to self-fulfilling prophecies. Youths may view themselves negatively because of their diagnostic label. In some cases, children may alter their behavior to fit the diagnostic label or use the diagnosis to excuse their behavior problems. Third, stigmatization can decrease the likelihood that families will seek psychological services. Many youths who show significant behavioral, emotional, and learning problems do not receive treatment because parents do not want them to receive a diagnosis (Martinez & Hinshaw, 2016).
Review
Only one-half of children with mental health problems receive treatment. Non-Latino White children and youths from high-SES families are most likely to receive care.
Roughly 7.5% of school-age children are taking at least one psychotropic medication at any point in time. Medication is more often used by adolescents (rather than children) and boys (rather than girls).
Barriers to treatment include financial problems, a lack of high-quality treatment in the community, a shortage of well-trained clinicians, and stigma.
1.3 Integrating Science and Practice
What Is Evidence-Based Practice?
The Importance of Science
Imagine that you experience unusual pain in your stomach that does not go away with the help of over-the-counter medicine. You schedule an appointment with your physician in the hope that she might be able to identify the cause of your ailment and prescribe an effective treatment. You would hope that your physician’s assessment, diagnostic, and treatment strategies are evidence based—that is, that they reflect the scientific research and best available practice (Rousseau & Gunia, 2016).
Psychologists and other mental health professionals who work with children and families also strive for evidence-based practice. According to the American Psychological Association (APA), evidence-based practice is “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences” (APA Presidential Task Force, 2006, p. 273). The purpose of evidence-based practice is to deliver the highest-quality mental health services to children, adolescents, and families and to promote mental health in the community (J. Hamilton, Daleiden, & Youngstrom, 2015).
Clinicians who adopt an evidence-based approach to their practice consider the following three factors when helping children and families in need:
Scientific research: According to the research literature, what methods of assessment and forms of treatment work best for children with this particular problem?
Clinical expertise: According to my own professional experience and judgment, what is the best way for me to assess and treat this child?
Patient characteristics: How might the child’s age, gender, and social–cultural background, or the family’s expectations and preferences for treatment, affect the way I help them?
Evidence-based practice, therefore, begins with consideration of the scientific research literature. If parents request treatment for their son with ADHD, which form of treatment is most likely to be helpful? Fortunately, professional organizations have identified evidence-based treatments—that is, psychotherapies and medications that have been shown in research studies to reduce children’s symptoms and improve their functioning. For example, the Society of Clinical Child and Adolescent Psychology (2020) maintains an excellent website, effectivechildtherapy.org, that describes the most empirically supported psychosocial treatments for childhood disorders. Similarly, the American Academy of Child and Adolescent Psychiatry (2020) issues guidelines to help physicians identify medications and psychosocial treatments that are effective for childhood disorders.
Evidence-based treatments are typically categorized into one of five levels, depending on how well they are supported by research (Figure 1.4). For example, a type of behavior therapy called “parent training” is considered a well-established treatment for children with ADHD because several high-quality experimental studies, conducted by independent teams of researchers, have shown that it reduces children’s ADHD symptoms. Consequently, behavior parent training, in which parents learn to monitor their children’s behavior and reinforce appropriate actions, is considered a first-line psychosocial treatment. Neurofeedback training, on the other hand, is considered possibly efficacious because it has less empirical support. Although one well-designed study suggests that this treatment can help children regulate brain activity and behavior, the study needs to be replicated before it can be considered a first-line treatment. In contrast, social skills training has questionable efficacy for treating ADHD. Most children with ADHD already have adequate social skills and know how to behave in social situations; their main problem is inhibiting their behavior long enough to implement this knowledge (Evans, Owens, & Bunford, 2014).
Evidence-based