Introduction
Parents sometimes come to clinicians with concerns about their children’s moods and behaviors, hoping for a rapid fix of the problem. Most child psychiatric issues can’t be fixed with just medication and respond better with psychotherapy or a combination of psychotherapy and medication. In the past 30 years, tremendous strides have been made in studying the effectiveness of psychotherapeutic interventions among youth.
Case Summary
Dr. Allison Hall
Katy is a 10-year-old girl who gets into arguments with her mother every day after school because she wants to walk to her grandmother’s house not far away. She was exposed to severe domestic violence by her father against her mother when she was 5 years old, and she has nightmares that cause her to wake up often at night, a fear of men, and rapid mood shifts into sudden rage as well as oppositional behavior with her mother. Her mother also has significant fears and views the world as a very unsafe place. She is worried that Katy has bipolar disorder because of her daughter’s rapid mood changes.
Discussion
While Katy has angry outbursts at times, she does not present with clear-cut episodes of elevated mood along with other symptoms of bipolar disorder, particularly grandiosity. Instead her presentation raises the possibility of post-traumatic stress disorder (PTSD) with nightmares, a fear of men who likely trigger past memories, and sudden mood shifts. Her mother also may have some elements of PTSD, which may be complicating Katy’s presentation. No medication interventions so far have demonstrated significant benefit in youth with PTSD. If further evaluation confirms PTSD, what sort of therapy should be sought for Katy?
A large number of websites now list evidence-based treatments, although many of those require that the creators of the treatment apply for inclusion, and do not address the issue of varying levels of evidence. The American Psychological Association has a website entitled Effective Child Therapy, which discusses psychotherapeutic interventions for various diagnostic areas in youth and the varying levels of evidence for such treatments based on the types and numbers of studies that support them. The website also has an excellent video resource library.
Trauma-focused cognitive-behavioral therapy has numerous studies supporting its efficacy for a wide range of traumas and includes work with both the parent and the child to address the ways the trauma can affect their interaction. This would be an excellent choice for Katy and her mother. Other therapies that have supporting research include child-parent psychotherapy, eye movement desensitization and reprocessing therapy, resilient peer treatment, child-centered therapy, and family therapy for PTSD. Treatments have usually been designed for specific ages, so it is important to consider whether the intervention fits the age of the child.
The extent to which evidence-based treatments are available in the community is variable. However, pediatricians can play a significant role in the availability of these interventions by being aware of which ones are most strongly supported, asking the therapists to whom they refer what their experience is with such interventions, and encouraging training in their offices and communities. Therapists should be comfortable describing exactly how much training they have had in a certain area, for instance, extensive training through their professional education or one or several postgraduate trainings, preferably with follow-up consultation with an experienced practitioner while they are seeing their first cases with a particular intervention.
There is controversy about evidence-based treatment among some psychotherapists who argue that the strict requirements of the research setting make the results inapplicable to the complexity of patients seen in typical clinical settings. In fact, many of the treatments, including trauma-focused cognitive-behavioral therapy, work very well in complex families. Certainly there is much more to learn about how to help patients who don’t respond to certain types of therapy or how to engage families who are reluctant to participate in treatment, but the treatments that we know work are clearly what we should choose first.
Dr. Hall is an assistant professor of psychiatry and pediatrics at the University of Vermont, Burlington. Dr. Hall said she had no relevant financial disclosures. To comment, e-mail her at pdnews@frontlinemedcom.com.