Brain-Based Therapy with Children and Adolescents E-Book

John B. Arden

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch
• Veröffentlichungsjahr: 2008

Seitenzahl: 586

Beschreibung

Designed for mental health professionals treating children and adolescents, Brain-Based Therapy with Children and Adolescents: Evidence-Based Treatment for Everyday Practice is a simple but powerful primer for understanding and successfully implementing the most critical elements of neuroscience into an evidence-based mental health practice. Written for counselors, social workers, psychologists, and graduate students, this new treatment approach focuses on the most common disorders facing children and adolescents, taking into account the uniqueness of each client, while preserving the requirements of standardized care under evidence-based practice.

Leseprobe

Table of Contents

Title Page

Copyright Page

Dedication

Acknowledgements

Preface

CHAPTER 1 - Changing and Staying the Same

NEURODYNAMICS: SELF-ORGANIZATION AND CHILD DEVELOPMENT

DEVELOPING BRAIN

NEUROPLASTICITY

CHAPTER 2 - Temperament and Neurodynamics

CLASSICAL VIEWS

TEMPERAMENT IN CONTEMPORARY PSYCHOLOGY

CHANGING THE GIVENS

COMMUNICATING EMOTIONS

EMOTION-REGULATING RELATIONSHIPS

CHAPTER 3 - Attachment and Subjectivity

FREUD, KLEIN, AND WINNICOTT

ATTACHMENT

ATTACHMENT, EMOTION REGULATION, AND PSYCHOPATHOLOGY

METACOGNITION AND SELF-REGULATION

CHAPTER 4 - Rupture and Repair in Caregiving Relationships

ATTACHMENT RUPTURES AND THE BRAIN

MATERNAL DEPRESSION

STRESS, DEVELOPMENT, AND PARENTAL ABUSE

COCONSTRUCTING NARRATIVES

MANAGING AFFECT

THEORY OF MIND

CHAPTER 5 - Adolescence

HORMONES, GROWTH, AND SEX

PSYCHOLOGICAL DEVELOPMENT

PARENTING

CHAPTER 6 - Working from the BASE

B IS FOR BRAIN

A IS FOR ATTUNEMENT

S IS FOR SYSTEMS

E IS FOR EVIDENCE-BASED

CHAPTER 7 - Disorders of Attention and Self-Regulation

DIAGNOSIS

PREVALENCE AND COMORBIDITIES

ASSESSMENT

ETIOLOGY AND NEURODYNAMICS

TREATMENT OF ADD/ADHD

TREATING PARENTS AND FAMILIES

WORKING WITH SCHOOLS

PROGNOSIS

CHAPTER 8 - Anxiety in Children and Adolescents

DISPOSITIONAL FACTORS

CHILD AND ADOLESCENT OBSESSIVE-COMPULSIVE DISORDER

SOCIAL ANXIETY DISORDER

POSTTRAUMATIC STRESS DISORDER

CHAPTER 9 - Depression in Children and Adolescents

INCIDENCE AND PREVALENCE

DIAGNOSIS

ASSESSMENT

ETIOLOGY

ATTACHMENT, RELATIONSHIPS, AND MOOD

TREATING CHILDHOOD AND ADOLESCENT DEPRESSION

APPENDIX - Primer on the Brain

References

AUTHOR INDEX

SUBJECT INDEX

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Copyright © 2009 by John Wiley & Sons, Inc. All rights reserved.

Published by John Wiley & Sons, Inc., Hoboken, New Jersey. Published simultaneously in Canada.

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Library of Congress Cataloging-in-Publication Data:

Arden, John Boghosian. Brain-based therapy with children and adolescents : evidence-based treatment for everyday practice / by John Arden, Lloyd Linford. p. ; cm. Includes bibliographical references and index.

eISBN : 978-0-470-46621-6

1. Developmental psychobiology. 2. Child psychiatry. I. Linford, Lloyd. II. Title. [DNLM: 1. Mental Disorders-therapy. 2. Psychotherapy-methods. 3. Adolescent. 4. Child. 5. Evidence-Based Medicine-methods. 6. Psychophysiology. WS 350.2 A676b 2009] RJ131.A73 2009 618.92’89-dc22 2008022834

For our sons Paul and Gabe Arden and Zack and Scott Linford and those who will share their future

Acknowledgments

Brain-Based Therapy would not have come into existence without the support and contributions of many people. First and foremost, we are indebted to our wives, Vicki Arden and Pam Valois, for their encouragement, scalding editorial comments, and good-hearted willingness to sacrifice countless evenings and weekends to this project. The inspiration for this book emerged from conversations with clinical experts and scientists presenting at Kaiser’s Annual Northern California Psychiatry and Chemical Dependency Conference. We would like to thank the other members of the Conference’s planning group—Marion Lim-Yankowitz, Marilyn McPherson, Caryl Polk, and John Peters—who, over the last 16 years, have helped create these memorable gatherings in San Francisco. We would particularly like to thank Debbie Mendlowitz and Steve Miller for insuring that child work has had a place at the conference. Among the many outstanding academics and clinicians who contributed ideas they articulated on the conference podium, we especially thank Jim Grigsby, who helped formulate the idea for this book and edit the appendix, and Lou Cozolino, who has set a high standard for integrating neuroscience and psychotherapy in his own writing and clinical work. Conversations with Dr. Cozolino led to the idea for the BASE, a mnemonic that condenses our ideas about brain-based treatment into a practical and teachable form. Helen Mayberg’s work on depression from a neuroanatomical and neurodynamic perspective has shaped our thinking about depression.

Like a tripod, this book is supported by three legs, each in its own way indispensable to our model of brain-based therapy: neuroscience, attachment studies, and research into evidenced-based treatments for specific psychological disorders. Regarding the latter, we received ongoing support and stimulation from the members of Kaiser’s Best Practices Steering Committee, to whom we express our thanks. In particular we must acknowledge Elke Zuercher-White’s generous sharing of her scholarship and insight into the origins and treatment of OCD, panic disorder, and social anxiety disorder. Dr. Anna Wong, the leader of Kaiser’s ADHD Best Practices Workgroup and the coauthor of its clinical recommendations, changed our minds about ADD in two or three brilliant conversations about brain-based attentional disorders. Drs. Zuercher-White and Wong read and commented on chapters in the book that resulted in critical changes and improvements. Child psychologist and psychoanalyst Tom Cohen also read and made invaluable improvements to the chapter on ADHD. Dr. Daniel Pickar made editorial comments on the entire text. Without the ongoing dedication of our organization and its leader, Dr. Robin Dea, to child and family services, this book would not have been possible. One of us (LL) came to Kaiser in the 1970s because of its excellent training program in child treatment; another of us (JA) is now responsible for insuring that these high standards are carried forward for another generation of therapists. We would like to thank the Medical Center Training Directors, supervisors, interns, post-docs, and most of all the patients who have helped educate us about the psychology of the child.

Finally, we would like to thank the great team at Wiley whose professionalism and commitment to clinically relevant books is exemplary. Peggy Alexander, Marquita Flemming, Kim Nir, and Katie DeChants at Wiley have been generous and helpful throughout this project.

Although many excellent brains were involved in the creation of this book, only two are responsible for its errors and omissions.

—John Arden, Sebastopol, California —Lloyd Linford, Piedmont, California

Preface

Helping children in trouble is an aspiration that is for the most part built into the brains and hearts of adults, and predates our origins as Homo sapiens. But as an actual vocation in the western sense, it is quite recent. The child-helping professions originated in 19th-century Europe and America. Urbanization and factory-based work left parents with less time for their families, and children were exposed to many new challenges and stressors. Cut loose from their religious and agrarian moorings, social values began to drift. Widespread literacy and compulsory education fueled the process of change. Not coincidentally, child psychiatry, psychology, and social work all originated in this period. Social work was born in the slums of London and New York, and child psychology’s roots go back to 19th-century Austria and France. Siegfried Bernfeld (1922), August Aichorn (1926/1955), and Anna Freud (Burlington & Freud, 1940; Freud, 1946) blended their devotion to children with fealty to Sigmund Freud.

The approaches used by Anna Freud and others had, of necessity, to take stock of the unique challenges of working with children. While doing psychotherapy with adult patients may allow us to forget how embedded each individual is in a social system, children never let us forget this fact. The psychological assessment of a child must include an evaluation of the psychological strengths and weaknesses of parents and siblings, of actual sources of anxiety, and of actual experiences of trauma and loss.

The works of these early social workers, marriage and family counselors, and child psychologists continue to constitute the core curriculum for all students of our art, yet they all leave something out. They all underplay the actual basis for child psychology: the developing brain. As we suggested in Volume 1 of this series, Brain-Based Therapy with Adults, the two greatest minds in nineteenth-century psychology, Sigmund Freud and William James, were talented and expert neurophysiologists. Yet both abandoned the biological study of the brain in favor of more theoretical pursuits about how the mind works. Freud’s “Project for a Scientific Psychology” (1895/1958) sets out the aspirations shared by many psychotherapists today: to construct a theory of the mind (and therapy) that rests on solid biological evidence. Strangely, Freud never published the "Project” in his lifetime, whether because he had reservations about abandoning his work as a neurologist or for other reasons we will never know.

Understanding the neurobiology of attachment and relationships—how the brain insures the continuity of early patterns of relating and at the same time has the capacity for changing them—is basic to the new curriculum for child psychotherapists and pediatric residents. It is one thing to talk about this issue with adults, where therapists are preoccupied with brain changes that, in the developmental scheme of things, are more in the nature of a tune-up than a complete overhaul. It is another thing to look at the unfolding of the brain in children, where the changes are dramatic and ongoing. Children are exquisitely sensitive to the environment and change in relationship to it even before birth—and it is the brain that makes this apparent paradox of innate structure and almost infinite plasticity possible.

In our view, the most important development in psychology in the last decade is the emergence of attempts to synthesize developmental psychology, neuroscience, and psychotherapy. In the work of Schore (1994), Segal (1999), and Cozolino (2006), links have been made between the brain and the mind in psychodynamic therapy. Developmental pathology breaks new ground in taking a fundamentally integrative approach to the attachment literature of psychological theory (Cicchetti, et al, 2006; Sroufe et al., 2005). The biological approaches of Jerome Kagan and Mary Rothbart synthesize perspectives from the temperament literature and evolutionary biology (Kagan, 2004). Some long-standing theory-based observations—for example, Melanie Klein’s idea that parents have the capacity to project unconscious anger into their child, unconsciously identify with the anger, and then punish the child for aggressive behavior—suddenly makes sense on the biological as well as the clinical level (Klein, 1975/1921-1945). So far no one has attempted to apply these lessons specifically to working therapeutically with children in a broader psychological frame of reference. That is a goal of this book.

For most therapists, however, the big question is still "So what?” What difference will understanding how the brain develops and functions make in doing the actual work of child psychotherapy? How does this new knowledge relate to the ideas and clinical methods of such giants of child psychology as Anna Freud (Sandler & Freud, 1985), Piaget (1951), Winnicott (1941/1975; 1975), and Bowlby (1969)? What difference is it going to make when I next close the door and begin an hour with an active and oppositional child? In this volume, we hope to answer these questions, and the answers we propose are encouraging in terms of how much of the traditional theory and technique are not just salvageable in the new neurobiological frame of reference, but actually clarified and put on firmer ground.

For child psychotherapists, developmental neuroscience currently has an importance comparable to the role of the frontier in 19th-century America. Horace Greeley, a newspaperman of that period, advised a reader to "Go west, young man!” because Greeley saw that was where opportunity and the future were to be found. We feel similarly about the new frontier that is opening up as a result of developmental neuroscience: it is a domain of knowledge that is rich and attainable, and it will become vital territory in the career of psychotherapists. To produce lasting change in developing children, we must understand how young brains (as well as young minds) work. The approach offered in this book attempts to synthesize what is known about developing brains and the therapeutic approaches that have been supported by research. By combining the findings of developmental neuroscience with evidence-based practice, we offer a brain-based therapy for children.

CHAPTER 1

Changing and Staying the Same

No matter where you go, life moves forward like a heavy wheel and it never stops regardless of any circumstance. It just moves forward regardless, and I find that extremely humbling.

—Lisa Kristine, Photographer

CHILD THERAPISTS WORK in the space between the stable and changeable aspects of personality and character, using the therapeutic relationship to promote a healthy adaptation to living in a complex social world. The discovery that such a relationship could change the mind ignited the psychotherapeutic revolution in psychiatry. It does not seem widely remembered that the discovery was made by pioneers who at the time were immersed in the study of the brain and nervous system. Between 1877 and 1900 (when The Interpretation of Dreams was published), Freud authored more than 100 works on neuroscience. (For an interesting discussion, see Solms & Saling, 1990.) As a neurologist, Freud revised the prevailing view of his scientific contemporaries that the brain did its work piecemeal, with specific parts performing particular tasks in a straightforward way. In a short article on aphasia, for example, Freud rejected the localization hypothesis in favor of the concept of a "speech field” in the brain (1888/1990), a view more in accord with that of modern neuroscience.

Like Freud, William James was also a neurophysiologist. While his work is ultimately less useful to clinicians than Freud’s, James nonetheless laid the basis for much of current cognitive science, and in that sense was a precursor to behaviorism and cognitive behavioral therapy. In his 1890 Principles of Psychology, James discusses some ideas that came to have enduring importance in psychological studies, including associative learning, chains of operant learning, and fear conditioning. His theory of emotion was based on the idea that feelings arise not from thoughts or fantasies but rather from visceral and muscular responses to outside stimuli. The Principles of Psychology includes detailed diagrams of the brain and a review of Broca and Wernicke’s areas (two areas of the brain that are key to our ability to express and understand language). Regarding the seat of consciousness, James concluded:

For practical purposes, nevertheless, and limiting the meaning of the word consciousness to the personal self of the individual, we can pretty confidently answer the question prefixed to this paragraph by saying that the cortex is the sole organ of consciousness in man. If there be any consciousness pertaining to the lower centres, it is a consciousness of which the self knows nothing. (James, 1890, p. 67)

Subsequent clinically-oriented psychologists followed Aristotle, Descartes, and James in largely disregarding the brain, and followed Freud in focusing on case studies and on developmental cognitive and behavioral norms. Abandoning brain science in favor of pure psychology allowed psychotherapists to employ methods considered "unscientific’ by biological scientists. These included the use of insight and empathy as ways of understanding the mind. The separation from neurology allowed therapists to grasp a truth about neuroscience that for many years eluded scientists in laboratory: the brain is exquisitely sensitive to the interpersonal environment of relationships. Particularly in childhood, relationships are as important as food and warmth.

Psychotherapy’s discoveries about human nature and development outstripped what could be demonstrated in the neuroscience labs of the same period. But in pursuing the purely psychological strategy of Freud and James, those of us who have grown up in the psychodynamic and behavioral traditions postponed an important reality check on intuitive hypothesizing and speculation.

The way in which contemporary neuroscience causes us to revise the common psychodynamic understanding of unconscious phenomena exemplifies the value of an integrated neurodevelopmental model. Classical psychoanalytic theorists tended to portray the unconscious as the Puritans portrayed hell—a cauldron of aggressive and libidinal impulses threatening to spill over and destroy both the social order and the individual’s cohesive sense of goodness. Later psychodynamic therapists viewed it in less vivid terms, as the repository for socially and personally unacceptable impulses. In contemporary neuroscience, if the Freudian unconscious exists at all, it is seen as a small subset of a much larger area of mental life that functions outside of awareness. Much of what the brain does never achieves consciousness, nor would there be a purpose in its doing so. Neuroscientists are careful to use the term “nonconscious” as an adjective, not (as the Freudians tend to do) as a noun. The mind, in the new neuroscience, is a process rather than a thing or a place. Neurodynamic therapists are less impressed with insight than with integrating brain functions and the psychological domains of thought, emotion, and behavior.