The Handbook of Child and Adolescent Clinical Psychology

The Handbook of Child and Adolescent Clinical Psychology

7 1 0 2 t s u g u A 2 2 0 1 : 9 0 t a 9 1 2 . 9 5 . 8 3 1 . 5 8 y b d e d a o l n w o D

A contextual approach Third edition

Alan Carr

First published 2016 by Routledge 2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN and by Routledge 711 Third Avenue, New York, NY 10017 Routledge is an imprint of the Taylor & Francis Group, an informa business

© 2016 Alan Carr The right of Alan Carr to be identified as author of this work has been asserted by him in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988.


All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice : Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Cataloging-in-Publication Data Carr, Alan. The handbook handbook of child and adolescent clinical psychology : a contextual contextual approach approach / authored by Alan Carr. — Third edition. pages cm Includes bibliogr bibliographical aphical references and index. 1. Child psychol psychology—Handbo ogy—Handbooks, oks, manuals, etc. 2. Adolescent psychol psychology— ogy— Handbooks Handb ooks,, manua manuals, ls, etc etc.. I. Titl Title. e. RJ503.3.C37 2016 618.92'8914—dc23 2015024611

ISBN: 978-1-138-80600-9 (hbk) ISBN: 978-1-138-80613-9 (pbk) ISBN: 978-1-315-74423-0 (ebk) Typeset in Times by Apex CoVantage, LLC

Contents


List of gures gures List of tables List of boxes Prefacee to the third Prefac third edition Acknowledgements Acknowledgem ents

vii x xiv xvii xxi

SECTION 1

Frameworks Framew orks for practice 1 Normal developmen developmentt

1 3

2 Inuences on problem development

36

3 Classicati Classication, on, epidemiology and treatment effective effectiveness ness

66

4 The consultation process and intake interviews

97

5 Report writing

147

SECTION 2

Problems of infancy and early childhood

173

6 Sleep problems

175

7 Toileting problems

204

8 Intellectual Intellectual,, learning and communication disabilities and disorders

229

9 Autism spectrum disorders

284

vi

Contents

SECTION 3

Problems of middle childhood


315

10 Conduct problems

317

11 Attention and over-activity problems

366

12 Fear and anxiety problems

399

13 Repetition problems

473

14 Somatic problems

509

SECTION 4

Problems in adolescence

575

15 Drug misuse

577

16 Mood problems

617

17 Anorexia and bulimia nervosa

687

18 Psychosis

728

SECTION 5

Child abuse

785

19 Physical child abuse

787

20 Emotional abuse and neglect

816

21 Sexual abuse

841

SECTION 6

Adjustment to major life transitions

885

22 Foster care

887

23 Separation and divorce

907

24 Grief and bereavement

936

References Index

967 1037

Figures


1.1 2.1 2.2 2.3 2.4 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 4.10 4.11 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9 5.10 5.11 6.1 6.2

Well-being and strains across the family lifecycle Predisposing, precipitating precipitating,, maintaining and protective factors for child and adolescent psychological problems Attachment styles Patterns of parenting Marital satisfaction across the lifespan Stages of the consultation process Framework for planning the agenda for assessment interviews Intake form Genogram symbols The Boyle genogram completed in 1994 Child-centred Child-centre d assessment: Example of a genogram, lifeline and indicators of emotional climate used in a child-centred assessment Children’s Global Assessment of Functionin Functioning g Scale (C-GAS) Systemic Clinical Outcome and Routine Evaluation (SCORE) Global Assessment of Relational Functioning Scale (GARF) Process of recursive re-formulat re-formulation ion Karpman’s triangle Example of progress notes from an assessment session Example of progress notes from a treatment session Example of a comprehensive assessment report Example of an end-of-episode case summary Example of a letter to a referring agent Example of a letter to a client Framework for writing a case study Relationships Relationshi ps between various types of reports arising out of psychological consultations Clinic audit form Client audit form Referrer audit form Typical sleep requiremen requirements ts in childhood Factors to consider in childhood sleep problems

8 37 49 51 52 98 99 103 110 112 114 118 121 123 124 125 149 149 152 154 157 158 161 163 165 166 167 177 188

viii Figures

6.3 6.4 7.1 7.2 7.3


7.4 7.5 7.6 8.1 8.2 10.1 10.2 10.3 10.4 10.5 10.6 10.7 11.1 12.1 12.2 12.3 12.4 13.1 13.2 13.3 13.4 13.5 14.1

14.2 14.3 14.4 14.5 14.6 15.1 16.1 16.2 16.3

Sleep diary Child’s star chart for sleep problems Prevalence of wetting and soiling from birth to adolescence Parent recording chart for monitoring changes in soiling and/or wetting Parent recording chart for monitoring diet, uids, exercise and laxative use Factors to consider in enuresis Factors to consider in encopresis Child’s star chart for enuresis and encopresis A report on a case of specic reading disorder disorder (or dyslexia) dyslexia) A framework for assessment of adjustment problems in cases of traumatic brain injury Factors to consider in childhood conduct problems Four-column Four-colum n chart for monitoring antecedents and consequences of positive and negative target behaviours Child’s reward chart for conduct problems Time-out monitoring chart Points chart Privileges and nes Daily report card Factors to consider in the assessment of ADHD Factors to consider in childhood anxiety problems Fear tracking form Relaxation exercises handout for parents and young people Factors to consider in the assessment of school refusal OCD ladder Factors to consider in OCD Exposure and response prevention homework sheet Tic recording form for assessing antecedents and consequences throughout the day Tic recording form for assessing assessing the number number of tics tics in in a single time slot over a week Psychological and physiological dimensions along which the aetiology and symptomatol symptomatology ogy of typical paediatric presentations fall Factors to consider in the assessment of somatic complaints Pain diary Self-monitoring Self-monitor ing system for physical illnesses Child’s reward chart for use with somatic complaints Aetiological factors for headaches Factors to consider in adolescent drug misuse Factors to consider in the assessment of depression Model of depression for psychoeducation Self-monitoring Self-monitor ing form for depression

190 198 209 214 215 216 217 222 256 273 339 349 351 352 353 354 355 383 441 447 449 455 484 487 493 502 503

513 522 544 545 546 552 586 648 653 656

Figures ix

16.4 16.5 17.1 17.2 18.1 18.2 18.3 19.1 19.2


20.1 20.2 21.1 21.2 21.3 22.1 22.2 23.1 23.2 24.1

Mindfulness of breathing Formulation model for suicide risk and self-harm Factors to consider in the assessment of eating disorders Self-monitoring Self-monitori ng form for bulimia A diathesisdiathesis-stress stress model of schizophr schizophrenia enia Factors to take take into into account account in in the assessment of psychosis psychosis Psychoeducational notes for parents of young young people people with with psychosis psychosis Model of the sequence sequence of events leading to a physically abusive act act Risk and and protective protective factors factors to consider in the assessment of physical physical child abuse Four feeding feeding patterns associated with non-organi non-organicc failure failure to thrive thrive Risk and protective protective factors factors to consider consider in the assessment assessment of neglect, neglect, emotional abuse and related problems Model of pattern pattern of interaction in which which repeated repeated sexual sexual abuse may be embedded Factors to consider consider in the the assessment assessment of child child sexual sexual abuse Taking action following an allegation of child sexual abuse A co-operativ co-operativee foster care system A conictual foster care system Factors contributing to parental post-separati post-separation on adjustment and parenting capacity capacity Factors contributin contributing g to children’s adjustment following separation or divorce Factors to consider in the assessment of children’s grief reactions

661 672 709 716 749 763 775 795 797 826 829 846 849 858 897 898 910 916 951

Tables


1.1 1.2 1.3 1.4 2.1

Stages of the family lifecycle Development of motor and sensory skills Development of emotional competence Newman’s revision of Erikson’s psychosocial stage model Functional and dysfunctional problem, emotion and avoidance focused coping strategies 2.2 Defence mechanisms at different levels of maturity 3.1 Main ICD-10 disorders 3.2 Main DSM-5 disorders 3.3 Structured interviews and screening instruments for assessing psychological symptomatology in children and adolescents 3.4 Kappa reliability coefcients for diagnoses of four childhood psychological disorders 3.5 Empirically derived syndromes assessed by the Child Behaviour Checklist and related ASEBA instruments 3.6 Main DC: 0–3R axis I clinical disorders 3.7 Broad problem areas in clinical child psychology 3.8 Point prevalence of psychological disorders as assessed by the DAWBA in boys and girls in the UK in 1999 and 2004 3.9 Co-morbidity in community populations for four major DSM diagnostic categories 3.10 Co-morbidity in community and clinic populations for four major syndromes on child and parent completed versions of ASEBA behaviour checklist 3.11 Factors inuencing the outcome of psychological treatment of children 4.1 Psychometric instruments that may be used routinely as an adjunct to clinical interviews in the assessment of child and family problems 4.2 Guidelines for listening and communication skills 4.3 Guidelines for problem-solving skills 4.4 Guidelines for supportive play 4.5 Guidelines for reward systems 4.6 Guidelines for behavioural control programmes

4 9 21 27 42 44 68 72 78 79 84 87 88 91 92

92 93

116 136 137 138 139 140

Tables

6.1 6.2 6.3


Diagnosis of dyssomnias Diagnosis of parasomnias Goodlin-Jones and Anders classication and diagnostic criteria for sleep onset and night-waking disorders and ASEBA Sleep Problems syndrome scale 6.4 Psychometric instruments that may be used in the assessment of children’s sleeping and eating problems 7.1 Diagnosis of elimination disorders 7.2 Theories of elimination disorders 8.1 Diagnosis of intellectual disability 8.2 Psychometric instruments for the assessment of intelligence and general cognitive abilities 8.3 Psychometric instruments for the assessment of adaptive behaviour 8.4 Instruments for assessing children with motor and sensory impairments 8.5 Diagnosis of language disorder 8.6 Tests for assessing language and attainment problems 8.7 Diagnosis of specic learning disorder 8.8 A procedure for interpreting the WISC-IV 8.9 Diagnostic criteria for learning disorders caused by traumatic brain injury 8.10 Neuropsychological assessment batteries for use with children 9.1 Diagnosis of autism spectrum disorders 9.2 Clinical features of ASD 9.3 Theories of ASD 9.4 Psychometric instruments for screening and assessing young people with ASD 9.5 Examples of behavioural treatment strategies for managing problems presented by young people with ASD 10.1 Outcome for adults identied as conduct disordered during childhood or adolescence compared with control groups 10.2 Diagnosis of oppositional deant disorder 10.3 Diagnosis of conduct disorder 10.4 Clinical features of disorders of conduct 10.5 Theories and treatments for conduct disorder and oppositional deant disorder 11.1 Diagnosis of ADHD and attention decit and hyperactivity syndromes 11.2 Clinical features of ADHD 11.3 Theories of ADHD and treatment implications 11.4 Psychometric instruments that may be used as an adjunct to clinical interviews in the assessment of ADHD 12.1 Fears at different ages 12.2 Diagnosis of separation anxiety disorder 12.3 Diagnosis of mutism 12.4 Diagnosis of phobias 12.5 Diagnosis of generalized anxiety disorder

xi

178 182

183 191 207 210 231 233 235 241 242 243 245 265 269 275 287 290 292 300 308 318 322 323 325 327 369 372 381 388 400 405 407 408 412

xii Tables

12.6 12.7 12.8 12.9 12.10 13.1 13.2 13.3


13.4 13.5 14.1 14.2 14.3 14.4 15.1 15.2 15.3 15.4 15.5 15.6 15.7 16.1 16.2 16.3 16.4 16.5 16.6 17.1 17.2 17.3 17.4 17.5 18.1

Diagnosis of panic disorder and agoraphobia Diagnosis of PTSD Clinical features of anxiety disorders in children Theories and treatments for anxiety Psychometric instruments for the assessment of anxiety disorders in children and adolescents Diagnosis of OCD Theories and treatments for OCD Psychometric instruments that may be used as an adjunct to clinical interviews in the assessment of OCD Diagnosis of Tourette’s disorder Psychometric instruments that may be used as an adjunct to clinical interviews in the assessment of Tourette’s disorder ASEBA Somatic Complaints syndrome scale for 1.5–5 and 6–18 year olds Prevalence of various illnesses in children Psychological theories and treatments for somatization problems, conversion problems and problems of adjustment to illness Psychometric instruments for the assessment of somatic complaints Diagnosis of substance use disorders Clinical features of substance-induced disorders listed in DSM-5 and ICD-10 Intoxication and withdrawal syndromes and substance-induced disorders for substances listed in DSM-5 Clinical features of drug misuse Theories of drug misuse The 12 steps of Narcotics Anonymous Psychometric instruments for the assessment of drug misuse Diagnosis of major depressive episode ASEBA Anxious-Depressed and Withdrawn-Depressed syndrome scales for 1.5–5 and 6–18 year olds Clinical features of depression in children and adolescents Theories of depression Psychometric instruments for the assessment of depressed young people Denitions of bipolar disorder Diagnosis of anorexia and bulimia nervosa Clinical features of eating disorders in children and adolescents Risk factors for eating disorders Theories of eating disorders Instruments for the assessment of eating disorders Positive symptoms, negative symptoms and disorganization which occur in psychosis

415 419 423 427 437 475 478 485 497 500 511 513 514 536 581 582 583 587 591 594 604 621 623 625 628 646 664 690 693 695 696 705 731

Tables xiii

18.2 18.3 18.4 18.5 18.6 18.7 18.8 19.1 19.2 7 1 0 2 t s u g u A 2 2 0 1 : 9 0 t a 9 1 2 . 9 5 . 8 3 1 . 5 8 y b d e d a o l n w o D

19.3 19.4 19.5 20.1 20.2 20.3 20.4 20.5 21.1 21.2 21.3 21.4 23.1 23.2 23.3 23.4 23.5 24.1 24.2 24.3 24.4

Diagnosis of schizophrenia Clinical features of psychosis and schizophrenia Risk factors for schizophrenia Risk factors for a poor outcome in schizophrenia Theories of psychosis Psychometric instruments for the assessment of psychosis and related constructs in children and adolescents Positive and negative coping strategies used to manage psychotic symptoms Checklist of items that raise suspicion of physical child abuse Components of a comprehensive child protection assessment package for use in cases of physical child abuse Checklist of four conditions that predict positive treatment response in families where child abuse has occurred Goals that may be targets for specic interventions in cases of child abuse and neglect Components of physical child abuse prevention programmes Main features of neglect and emotional abuse Diagnosis of reactive attachment disorder and related syndromes Main features of non-organic failure to thrive and psychosocial dwarsm Psychometric instruments that may be used as an adjunct to clinical interviews in the assessment of physical child abuse and neglect Components of a comprehensive child protection assessment package for cases of neglect or emotional abuse A framework of factors indicative of child sexual abuse Components of a comprehensive child protection assessment package for use in cases of child sexual abuse Psychometric instruments that may be used as an adjunct to clinical interviews in the assessment of child sexual abuse Core concepts in curricula of CSA school-based prevention programmes Extra stages in the family lifecycle entailed by separation or divorce and re-marriage Structured assessment instruments for use in cases of separation or divorce Areas requiring assessment for custody evaluation Criteria for deciding for or against joint custody Criteria for deciding for or against custody as being in the best interests of the child Behavioural expressions of themes underlying children’s grief processes following bereavement or facing terminal illness that may lead to referral DSM-5 proposed criteria for persistent complex bereavement disorder Theories of grief Psychometric instruments that may be used as an adjunct to clinical interviews in the assessment of grief and related constructs

734 735 739 740 742 756 771 792 802 803 805 813 819 822 825 830 835 854 860 864 881 918 920 929 930 930 942 944 945 958

Boxes


6.1 7.1 7.2 8.1 8.2 8.3 9.1 10.1 11.1 12.1 12.2 12.3 12.4 12.5 12.6 13.1 13.2 14.1 14.2 14.3 14.4 14.5 15.1 15.2 16.1 17.1 18.1 19.1 20.1

A case example of a child with a sleep problem A case of enuresis A case of encopresis A case of intellectual disability A case of language disorder A case of traumatic brain injury A case of ASD A case example of conduct disorder: Bill, the boy on the roof A case example of ADHD: Timmy, the motorboat A case of separation anxiety and school refusal A case of selective mutism A case of a specic phobia A case of generalized anxiety disorder A case of panic disorder with agoraphobia A case of PTSD A case of OCD A case of Tourette’s disorder A case of recurrent abdominal pain A case of severe migraine A case of conversion symptoms A case of asthma A case of poorly controlled diabetes A case of polysubstance misuse A case of early drug experimentation A case of adolescent depression A case of anorexia nervosa A case of rst-episode psychosis: Julian, the boy who ran east A case of physical child abuse A case of neglect, non-organic failure to thrive and inhibited reactive attachment disorder

194 204 205 230 250 268 284 318 367 403 406 408 411 413 418 474 496 526 528 529 530 532 577 579 617 687 728 788 816

Boxes

21.1 21.2 22.1 23.1 24.1


A case of intrafamilial sexual abuse A case of extrafamilial sexual abuse A case of foster care: The Rogers A case example of adjustment problems following separation A case study on bereavement

xv

841 843 887 907 936


Preface to the third edition


When a dog barks late at night and then retires again to bed he punctuates and gives majesty to the serial enigma of the dark, laying it more evenly and heavily upon the fabric of the mind. King Sweeney in the trees hears the sad baying as he sits listening on a branch, a huddle between earth and heaven; and he hears also the answering mastiff that is counting the watches in the next parish. Bark answers bark till the call spreads like re through all Erin. Soon the moon comes forth from behind her curtains riding full tilt across the sky, lightsome and unperturbed in her immemorial calm. The eyes of the mad king upon the branch are upturned, whiter eyeballs in a white face, upturned in fear and supplication. Was he mad? The more one studies the problem the more fascinated one becomes. Flann O’Brien (1939). At Swim Two Birds (pp. 216–217). London: Penguin.

The current edition of this volume, like its predecessors, has been written as a core textbook in the practice of child and adolescent clinical psychology for postgraduates undertaking professional training in clinical psychology. The third edition of this handbook differs from the previous editions in a number of ways. Throughout the book references, website addresses and text have been updated to reect important developments since the publication previous editions. Recent research ndings on the epidemiology, aetiology, course, outcome, assessment and treatment of all psychological problems considered in the book have been incorporated into the text. Priority has been given to replicated ndings and those for which there is recent meta-analytic support. Account has been taken of changes in the diagnosis and classication of child and adolescent psychological problems reected in the fth edition of the American Psychiatric Association’s (2013) diagnostic and statistical manual (DSM-5), the revised Zero to Three (2003) diagnostic classication (DC: 0–3R), and the 11th revision of the American Association on Intellectual and Developmental Disabilities’ (2010) manual for the denition and classication of intellectual disability (AAIDD-11). Despite these extensive revisions and additions, the original structure of the handbook has been retained. A set of conceptual frameworks for practice is given at the outset, and then problems commonly encountered in clinical work with children and adolescents are considered. I have used the term contextual to describe the broad approach taken in this handbook, although I was tempted to describe it as multi-systemic, developmental and pan-theoretically integrative, since it is all of these things. The approach is multi-systemic, insofar as it rests on

xviii



the assumption that children’s psychological problems are most usefully conceptualised as being nested within multiple systems including the child, the family, the school and the wider social network. It is also multi-systemic insofar as it assumes that assessment and intervention must address the systems relevant to the aetiology and maintenance of the particular problem with which the child presents. Ecological models of child development and family-based intervention strategies have been a particularly strong inuence on the development of this approach. The approach is developmental because it takes account of the literature on individual lifespan development, developmental psychopathology and the family lifecycle. The approach is pan-theoretical insofar as it rests on an acceptance that useful solutions to young people’s difculties may be developed by considering them in light of a number of different theoretical perspectives rather than invariably attempting to conceptualize them from within a single framework or theoretical model. Neurobiological, cognitive-behavioural, psychodynamic, stress and coping, family systems, and social-ecological theories are the main conceptual frameworks considered within this approach. The approach is integrative insofar as it attempts, through a commitment to rigorous case formulation, to help clinicians link together useful ideas from different theories in a coherent and logical way when dealing with particu lar problems. A piecemeal, eclectic approach is thereby avoided. The overarching framework that has guided the development of this approach is rigorous social constructionism. There is an assumption that for children, families and clinical psy chologists, problem denitions and solutions are socially negotiated within the constraints of the physical world and physiological limitations of the body. Thus we can never ask if a particular diagnostic category (like DSM depression) or construct (like insecure attachment) is really true. All we can say is that for the time being, making distinctions entailed by these categories t with observations made by communities of scientists and clinicians and are useful in understanding and managing particular problems. The challenge is to develop integrative models or methods for conceptualizing clinical problems that closely t with our scientist-practitioner community’s rigorous observations and requirements for workable and ethical solutions. The book is divided into six sections. In the rst section a number of frameworks for practice are given. These frameworks offer a way of thinking about both clinical problems and the process of psychological consultation. In Sections II, III and IV, problems that commonly occur in early childhood, middle childhood and adolescence are discussed. Coverage of problems in these sections is not even-handed. Problems which are commonly referred for consultation are given greatest attention, with the exception of intellectual disabilities and neuropsychological problems. This is because in most clinical psychology training programmes (and indeed in our own programme at University College Dublin), these areas are covered by specialist courses and are only briey touched upon in the main clinical child psychology course. In Section V the focus is on child abuse, and in Section VI clinical problems associated with major life transitions, such as foster care placement, divorce and bereavement are considered. These topics are given special attention because managing cases where these transitions have occurred is a central part of the remit of clinical child psychologists. Within each of the chapters on specic clinical problems, case examples are given at the outset. These case examples have been sufciently disguised by altering details to protect the anonymity of clients. This is followed in most instances by a consideration of diagnosis, classication, epidemiology and clinical features. Reference is made to the tenth edition of World Health Organisation’s International Classication of Diseases (ICD-10; WHO, 1992, 1996) and fth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013). These systems are



xix

widely used, despite their many faults, and in my view, developing a familiarity with them and their shortcomings is an important part of training in clinical psychology. Theoretical explanations are considered after diagnosis and classication. Reference is made to available evidence and its bearing on various theoretical positions. However, extensive critical reviews of evidence are not given, since the central focus of this textbook is on practice rather than research. A summary of the empirical evidence on which much of the practice in this hand book is based is given in What Works With Children, Adolescents and Adults? (Carr, 2009). Frameworks for assessment and case management are given in light of available theories and research conclusions. In offering frameworks for assessment, an attempt has been made wherever possible to delineate important predisposing, precipitating, maintaining and protective factors deserv ing evaluation for the particular problem in question. Also reference is made to available psychometric instruments. In offering options for intervention, those for which there is evidence of efcacy are described wherever possible. Where research evidence is lacking, best practice based on available clinical literature and experience is offered. For most problems multi-systemic intervention approaches are described. These incorporate psychoeducational, child-focused, family-focused and broader network-focused elements. Summaries are given at the end of each chapter along with exercises to help postgraduates develop their formulation and case planning skills on the one hand, and their interviewing and consultation skills on the other. I have attempted wherever it seemed useful to offer diagrammatic summaries of material presented within the text and also to list practice manuals, resources for clients and websites at the end of each chapter. This text, in my view, has ve main shortcomings. First, I have over-emphasized problems and decits and under-emphasized the extraordinary resilience and resourcefulness that characterizes most children and families who come to the attention of clinical psychologists. This is probably because the entire eld is dominated by a decit discourse. My book – Positive Psychology (Carr, 2011) – offers a more resource-oriented perspective and may be read as a useful balance to the decit-dominated perspective of this handbook. Second, I have over-emphasized technical aspects of the consultation process and probably paid insufcient attention to relationship factors in clinical practice. My hope is that through live supervision during placements and internships and through experiential work or personal psychotherapy, students will develop interpersonal sensitivity and enhanced relationship skills. Third, the book is under-referenced. I took a decision to make a few references in the opening sentences of each section to major texts or signicant papers to substantiate assertions made throughout the section. I hoped that this would enhance the readability of the material and prevent the lack of uency that occurs when all assertions are multiply referenced. Fourth, many issues have not been covered or have been dealt with only briey. This is because I wished to keep the book to manageable proportions. Finally, this book is far too long. I began with the intention of writing a very short practical clinical text, but conversations with students and clinical placement supervisors repeatedly alerted me to other areas requiring coverage. Hence this oversized pocket book. The Handbook of Child and Adolescent Clinical Psychology is one of a set of three texts which cover the lion’s share of the curriculum for clinical psychologists in training in the UK and Ireland. The other two volumes, both of which are now in their second editions, are the Handbook of Adult Clinical Psychology: An Evidence Based Practice Approach and the Handbook of Intellectual Disability and Clinical Psychology Practice. Alan Carr University College Dublin January 2015


Acknowledgements


I am grateful to the many people who have helped me develop the ideas presented in this book. A particular debt of gratitude is due to the late Thérèse Brady who inspired me to begin the project and to all of the clinical psychology postgraduates who have challenged me to articulate my ideas on the nuts and bolts of case management in clinical practice. I am grateful to the many colleagues who have offered support in various ways while I was writing the current and previous editions of this book. Thanks also to all of the graduates of the doctoral programme in clinical psychology at UCD and the many postgrads who have emailed me or buttonholed me at conferences over the years to comment on aspects of previous editions and suggest how the book might be improved. Insofar as it was possible, I have tried to incorporate their feedback into this edition. Some of the more important insights into child and adolescent psychology have arisen within the context of my family, and so to them I am particularly grateful. We are grateful to the American Psychiatric Association for permission to reproduce diagnostic criteria previously published in 2013 in the fth edition of the Diagnostic and Statistical Manual of Mental Disorders and to the World Health Organization for permission to reproduce diagnostic criteria previously published in 1992 in the ICD-10 Classication of Mental and Behavioural Disorders. Clinical Descriptions and Diagnostic Guidelines. Alan Carr January 2015


Section 1

Frameworks for practice



Chapter 1

Normal development


This book is primarily concerned with psychological problems that occur during the rst 18 years of life. The rst 18 years is a period during which the most profound changes occur in physical, cognitive and social development. A summary of important normative ndings from the elds of developmental psychology and psychopathology will be presented in this chapter. However, the development of the individual child is primarily a social process and the family is the central social context within which this development occurs. We will therefore begin with a consideration of the family lifecycle.

The family lifecycle Families are unique social systems insofar as membership is based on combinations of biological, legal, affectional, geographic and historical ties. In contrast to other social systems, entry into family systems is through birth, adoption, fostering or marriage and members can leave only by death. Severing all family connections is never possible. Furthermore, while family members full certain roles which entail specic denable tasks such as the provision of food and shelter, it is the relationships within families which are primary and irreplaceable. With single-parenthood, divorce, separation and re-marriage as common events, a narrow and traditional denition of the family is no longer useful for the practicing clinical psychologist (Walsh, 2012). It is more expedient to think of the child’s family as a network of people in the child’s immediate psychosocial eld. This may include members of the child’s household and others who, while not members of the household, play a signicant role in the child’s life. For example, a separated parent and spouse living elsewhere with whom the child has regular contact, foster parents who provide respite care periodically, a grandmother who provides informal day care and so forth. In clinical practice the primary concern is the extent to which this network meets the child’s developmental needs. Having noted the limitations of a traditional model of the family structure, paradoxically, the most useful available models of the family lifecycle are based upon the norm of the traditional nuclear family, with other family forms being conceptualized as deviations from this norm (McGoldrick et al., 2011). One such model is presented in Table 1.1. This model delineates the main emotional transition processes and tasks to be completed by the family at each stage of development.

Table 1.1 Stages of the family lifecycle


Stage

Emotional transition processes

Tasks essential for developmental progression

Leaving home

Developing emotional and financial autonomy

Forming a couple

Committing to a long-term relationship

Families with young children

Accepting new children into the family system

Families with adolescents

Increasing flexibility of family boundaries to accommodate adolescents’ growing independence and grandparents’ increasing constraints

Launching children and moving into midlife

Accepting many exits from and entries into the family system

• Differentiating from family of origin and developing adult-to-adult relationship with parents • Developing intimate peer relationships • Beginning a career and moving towards financial independence • Establishing the self in community and society • Selecting a partner and deciding to form a long-term relationship • Developing a way to live together based on reality rather than mutual projection • Realigning couple’s relationships with families of origin and peers to include partners • Adjusting couple system to make space for children • Arranging childrearing, financial and housekeeping responsibilities within the couple • Realigning relationships with families of origin to include parenting and grandparenting roles • Realigning family relationships with community and society to accommodate new family structure • Adjusting parent–child relationships to allow adolescents more autonomy • Adjusting family relationships as couple take on responsibility of caring for aging parents • Realigning family relationships with community and society to accommodate adolescents’ increasing autonomy and grandparents’ increasing constraints • Adjusting to living as a couple again • Addressing couple’s midlife issues and possibilities of new interests and projects • Parents and grown children negotiating adult-to-adult relationships • Adjusting to include in-laws and grandchildren within the family circle

Normal development Stage


Emotional transition processes

Families with parents in late middle age

Accepting new generational roles

Families with parents nearing the end of life

Accepting the constraints of aging and the reality of death

5

Tasks essential for developmental progression

• Dealing with disabilities and death of couple’s aging parents • Realigning family relationships with community and society to accommodate new family structure and relationships • Maintaining couple’s functioning and interests, and exploring new family and social roles while coping with physiological decline • Adjusting to children taking a more central role in family maintenance • Making room for the wisdom and experience of the aging couple • Supporting the older generation to live as independently as possible within the constraints of aging • Realigning family relationships with community and society to accommodate new family structure and relationships • Dealing with loss of partner, siblings and peers • Preparing for death through life review and integration • Adjusting to reversal of roles where children care for parents • Realigning family relationships with community and society to accommodate changing family relationships

Note: Adapted from McGoldrick et al. (2011).

In the rst stage, which is marked by young adult children leaving home, the main process is the emergence of young adults’ emotional and nancial autonomy. The principal tasks are differentiating from the family of origin and developing adult-to-adult relationships with parents, developing intimate peer relationships, beginning a career and moving towards nan cial independence, and establishing the self within the community and society. The second stage is that of couple formation, where the main process is commitment to a long-term relationship. The principal tasks include selecting a partner and deciding to form a long-term relationship, developing a way to live together based on an appreciation of partners’ real strengths and weaknesses rather than mutual projection, and realigning couple’s relationships with families of origin and peers so as to accommodate partners. The third stage occurs when couples have children, and the main process is accepting new children into the family system. The principal tasks are making space within the couple’s relationship for children; arranging childrearing, nancial and housekeeping responsibilities within the couple; realigning relationships with families of origin to include parenting and grandparenting roles; and realigning family relationships with the community and society to

6


accommodate the new family structure. When couples adjust their roles to make space for young children, this involves the development of parenting roles which entail routines for meeting children’s needs for • • • •


safety care control intellectual stimulation.

Developing these routines is a complex process, and often difculties in doing so lead to a referral for psychological consultation. Routines for meeting children’s needs for safety include protecting children from accidents by, for example, not leaving young children unsupervised and also developing skills for managing frustration and anger that the demands of parenting young children often elicit. Failure to develop such routines may lead to accidental injuries or child abuse. Routines for providing children with food and shelter, attachment, empathy, understanding and emotional support need to be developed to meet children’s needs for care in these various areas. Failure to develop such routines may lead to a variety of emotional difculties. Children’s need for control are met through routines for setting clear rules and limits, for providing supervision to ensure that children conform to these expectations, and for offering appropriate rewards and sanctions for rule following and rule violations. Conduct problems may occur if such routines are not developed. Parent–child play and communication routines for meeting children’s needs for age-appropriate intellectual stimulation also need to be developed if children are to avoid developmental delays in emotional, language and intellectual development. The fourth stage of the family lifecycle model occurs when children make the transition to adolescence. At this stage the main developmental process is increasing exibility of family boundaries to accommodate adolescents’ growing independence and grandparents’ increasing constraints. The principal tasks at this stage are adjusting parent–child relationships to allow adolescents more autonomy, adjusting family relationships as the couple take on responsibility of caring for aging parents, and realigning family relationships with the community and society to accommodate adolescents’ increasing autonomy and grandparents’ increasing constraints. Good parent–child communication and joint problem-solving skills facilitate completion of some of the tasks in this stage of the family lifecycle. Skills decits in these areas underpin many adolescent referrals for psychological consultation. However, parents in families at this stage of development must contend not only with changes in their relationships with their maturing children, but also with the increased dependency of the grandparents upon them. The demands of grandparental dependency may compromise parents’ abilities to meet their adolescents’ needs for increasing autonomy. The fth stage of the family lifecycle is concerned with the transition of young adult children out of the parental home and the parents’ progression into midlife. The main process during this stage is accommodating exits from and new entries into the family system. During this stage a key task is the development of less hierarchical relationships between parents and children. Parents are also faced with the tasks of adjusting to living as a couple again, to dealing with disabilities and death in their families of origin, of adjusting to the expansion of the family if their children procreate, and realigning family relationships with the community and society to accommodate changes in the family structure. The acceptance of new generational roles arising from aging parents’ physiological decline is the main developmental process in the sixth stage of the family lifecycle. This stage is

Normal development


7

marked by aging parents moving into late middle life. The principal task for aging parents is to maintain functioning and interests and accept help and support from their adult children. The principal task for adult children is to take a more central role in family maintenance which includes arranging appropriate supports for their aging parents so that they can live as independently as possible within the constraints of aging. At this lifecycle stage families must also make room for the wisdom and experience of aging parents and realign family relationships with community and society to accommodate the new family structure. The acceptance of the constraints of aging and the inevitability of death is the main developmental process in the seventh stage of the family lifecycle, which is marked by parents nearing the end of life. The principal tasks include preparing for death through life review and integration, adjusting to reversal of roles where adult children care for parents, dealing with loss and realigning family relationships with the community and society to accommodate changing family relationships. The family must cope with aging parents’ physiological decline and approaching death, while at the same time developing routines for beneting from their wisdom and experience. This lifecycle model draws attention to the ways in which the family meets the developing child’s needs and also the way in which the family places demands upon children and other family members at different stages of the lifecycle. For example, the parents of a teenager may meet her needs for increasing autonomy by allowing greater freedom and unsupervised travel, and she may meet her grandparents’ needs for continued connectedness by visiting regularly. Family lifecycle models also focus attention on the transitions that the child and other family members must make as one stage is left behind and another stage is entered. For example, the transition from being a family with young children to being a family with teenage children requires a renegotiation of family rules and roles. The hierarchical relationship between the parents and children must be renegotiated, and in some families concurrently women may decrease their focus on homemaking while increasing their focus on their career. This may coincide with men taking a more active role within the household. Families require some degree of exibility to adapt the way relationships are organized as each of these transitions is negotiated. They also require the capacity to maintain stable roles and routines during each of the stages. A third important requirement is the capacity to permit children’s movement from dependency towards autonomy as development progresses. This is as true for the transition into adolescence as it is for the launching stage where young adult children are leaving home. A further feature of family lifecycle models is that they point to certain junctures where there may be a build-up of family stress with many individual transitions occurring simultaneously. For example, in the launching stage it is not uncommon for older children to be leaving home and having their rst children while their grandparents may be succumbing to late life illnesses or death. Often psychological difculties occur during such periods of transition. Data on changes in family members’ perception of strains and well-being, drawn from Olson’s (1993) study of US families, are set out in Figure 1.1. From this gure it may be seen that well-being is greatest during the early and later stages of the family lifecycle, whereas the childrearing years (those which are of central concern in this text) are associated with the highest level of stress. It is within the context of the family lifecycle that physical, cognitive and social development occurs, and it is to these that we now turn. The distinctions between physical, cognitive and social development are to some degree arbitrary since, for example, the development of moral reasoning (one aspect of social development) depends to some extent on the development of intelligence (an aspect of cognitive development). However, the distinctions provide

8



Figure 1.1 Well-being and strains across the family lifecycle Note: Adapted from Olson (1993).

a useful framework for summarizing those aspects of available research which are of particular relevance to the practice of clinical psychology.

Physical development Reviews of research on physical development paint the following picture of the infant’s growth (Illingworth, 1987; Rutter & Rutter, 1993; Shaffer & Kipp, 2014). At birth infants can distinguish good and bad smells and sweet, sour and salt avours. Even before birth, babies can respond to tactile stimulation and recognize their mother’s voice. The skill of localizing a sound is also present at birth. In the rst weeks of life infants can only focus on objects about a foot away and show a particular interest in dark–light contrasts. By 3 months they have relatively well-developed peripheral vision and depth perception and a major interest in faces. Visual acuity is usually fully developed by 12 months. Sensory stimulation is important for the development of the nervous system and inadequate stimulation may prevent normal neurological and sensory development. For example, children born with a strabismus (squint) which goes uncorrected may fail to develop binocular vision. When considering motor development a distinction is usually made between locomotion and postural development on the one hand, and prehension or manipulative skills on the other. The former concerns the development of control over the trunk, arms and legs for moving around. The latter refers to the ability to use the hands to manipulate objects. Some of the milestones of motor development are set out in Table 1.2. Also included here for convenience are some sensory skills which have already been discussed. Early observational studies led Arnold Gesell to propose a maturational theory of motor skills development (Gesell & Ames, 1940). He argued that motor skills development was genetically pre-programmed to follow proximodistal (from trunk to extremities) and cephalocaudal (from head to tail) progressions. So infants rst learn to

Normal development

9

control their arms before their ngers and their heads before their legs. Later research showed that motor development does not invariably follow these patterns. Esther Thelen drew on dynamic system theory to explain these exceptions (Thelen & Spencer, 1998). She proposed that motor development is multi-factorially determined. Key determinants include nervous system development, the biomechanics of the body and environmental constraints and supports.

Table 1.2 Development of motor and sensory skills


Age

Motor and sensory skills

0 months

• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

3 months

6 months

9 months

12 months

18 months

24 months

3 years

4 years

5 years

6 years 7 years

Turns head to one side when lying on stomach Legs make crawling movements when placed on stomach Holds a ring in a reflex grasp Can focus on objects 9 inches away Can distinguish mother’s voice Can distinguish sweet, sour and salt tastes Sits with support Pushes head and shoulders up when lying on stomach Grasps a rattle and reaches with two hands Breastfed children can distinguish their mother’s odour Shows interest in faces Depth perception emerges Sits briefly unaided Rolls from back to stomach Transfers cube between hands Walks holding furniture Crawls Sits alone Picks up button with thumb and forefinger Walks unaided Into everything Holds crayon and makes mark Climbs stairs Throws a ball into a box Builds a tower with three cubes Runs Walks backwards Puts square peg in square hole Builds a tower with six cubes Can stand on one foot for 5 seconds Pedals a tricycle Draws a circle Hops on one foot Buttons clothes Draws a square Hops on both feet Ties shoelaces Draws triangle Copies diamond Can learn new motor skills like throwing, riding a bicycle

Note: Adapted from Illingworth (1987).

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