BHIPP Bulletin

Volume 8, Issue 6

December 2022

This month's BHIPP Bulletin is a contribution from

Rick Ostrander, EdD, Associate Professor in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins School of Medicine,

Founder of Pediatric Medical Psychology Program at Johns Hopkins Children's Center and BHIPP Consultant.

A common assumption is that all therapies work equally and that every therapist knows how to treat all disorders. However, psychologists, social workers, counselors, and psychiatrists often use different treatment approaches to help children and adolescents. Scientific studies have identified specific psychosocial approaches as the most effective treatments available. Some of these therapies can serve as a stand-alone treatment or accommodate pharmacological approaches.

It is imperative that pediatric primary care providers have a basic understanding of the various types of evidence-based treatments for children's mental health issues in order to refer the family to the appropriate therapy. The following newsletter will briefly review the most current scientifically supported psychosocial treatments and which pediatric mental health issues they best address (Prinstein, Youngstrom, Mash & Barkley, 2019).

A comprehensive review is offered in the reference and links provided below. 

BEHAVIORAL MODIFICATION BASED THERAPIES:

Applied behavior analysis (ABA) teaches adaptive behaviors to developmentally immature or delayed individuals through behavior modification techniques. By analyzing a child’s circumstances, the therapist (or behavioral analyst) develops detailed plans for the caregiver (e.g., teacher or parent) to implement. This plan systematically analyses the circumstances that proceed and follow negative behavior. The developed plan sidetracks a behavior before it occurs and identifies the most effective way to reward prosocial behaviors and extinguish undesirable behaviors. When used with younger children, ABA interventions are called “Early Intensive Behavioral Interventions” (EIBI). ABA is considered a particularly effective treatment for autism spectrum disorder and related conditions associated with developmental delay.

Behavioral therapy changes the response of caregivers to a child’s behavior and replaces negative behaviors with more adaptive and prosocial behaviors. In comparison to ABA, behavioral therapy does not analyze the circumstances as systematically; likewise, behavioral interventions are not as detailed in their intervention approaches. However, like ABA, behavioral therapy aims to reduce problematic behaviors that may unknowingly or unintentionally get “rewarded.” For example, quieting a child’s temper outbursts by removing the child from the classroom may work temporarily but could unintentionally reward more temper tantrums. In this example, the reward may be tied to the child’s efforts to escape something the child finds anxiety-provoking (e.g., going to school). Although behavioral techniques can vary depending on the disorder, a common thread is that a behavioral therapist helps the child and caregivers find ways to reward desirable behaviors and replace negative behaviors. Specific behavioral therapy approaches address oppositional tendencies while other behavioral techniques address forms of anxiety. These treatments aim to help the parents to be the behavioral therapist at home. These approaches can be modified and applied to schools or treatment facilities. The respective behavioral therapies that address these concerns include parent training, other family-based treatments, and exposure techniques. 

Common behavioral therapies include the following:

• Behavioral Parent Training (BPT) is a time-limited program (usually 6-12 sessions) where therapists teach parents how to use behavioral modification techniques. In the process, parents learn ways to help their child or adolescent behave better. BPT is led by a mental health professional who meets parents in person, in groups, or in a virtual format. For young children, parents learn how to reward appropriate behavior and provide negative consequences for inappropriate behaviors through their day-to-day interactions with the child. For older children and adolescents, parents learn how to use charts and point systems with rewards and consequences. This approach to treatment has proven to be particularly effective with children diagnosed with ADHD and oppositional-defiant disorders; moreover, similar school-based approaches have likewise proven to be effective at treating these disruptive disorders.

• Family-Based Behavioral Treatment (FBT) treats young people suffering from various eating disorders. With FBT, the therapist helps the family understand the severe long-term implications of eating disorders. Through FBT, a therapist supports the parents in changing their response to their child suffering from either Anorexia or Bulimia. Moreover, the therapist helps foster a change in familial beliefs and behavior around eating. The therapist supports parents in regulating the child’s caloric intake and encouraging parental problem-solving around establishing healthy eating. Once the child achieves appropriate weight gain, the focus of therapy shifts to addressing any related psychological issues. This treatment is proven to be the most effective approach for patients confronting anorexia and bulimia.

• Family Skills Training has been found effective in helping the family to support individuals with severe problems with mood regulation. The focus of this approach is to help the family develop specific skills to support the young person in their medical treatment and overall adaptive functioning. This approach has proven to be particularly effective at treating the functional outcomes associated with bipolar disorder. 

• Habit Reversal Training is a behavioral approach that has been used in treating a variety of repetitive behavioral disorders. For example, the Comprehensive Behavioral Intervention for Tics (CBIT) involves the young person in treatment with parents often included in sessions. CBIT teaches patients to become aware of their tics and assists in developing competing behavior. Moreover, CBIT helps a patient change day-to-day activities in ways that will help reduce tics. CBIT is effective at significantly lowering tics in young people dealing with Tourette’s and other tic disorders. 

COGNITIVE BEHAVIORAL THERAPY:

Cognitive Behavioral Therapy (CBT) is a type of psychotherapy that helps people with internalizing disorders such as anxiety or depression.

CBT teaches individuals suffering from emotional disorders different ways of thinking, behaving, and reacting to situations. In the process, CBT helps individuals feel less depressed, anxious, and fearful. The therapy is held in either a group, family, or classroom setting. Parent participation is integral for this treatment for younger children. Personal involvement in CBT becomes more central for adolescents and older children. CBT is particularly effective for treating disorders related to anxiety, obsessive-compulsive disorder, depression, and reactions to trauma.

Common CBT techniques include the following:

• Exposure therapy is a CBT method used to treat anxiety disorders. Exposure therapy focuses on incrementally encouraging the young person to confront the fears that underpin an anxiety disorder and to help them to engage in activities they have been avoiding. Exposure therapy is often used along with relaxation exercises. 

• Cognitive restructuring is a technique that uses psychoeducational approaches to teach how distorted thinking underpins negative mood. Homework is used to encourage the young person to incorporate more positive beliefs into their day-to-day efforts to combat these distorted beliefs. 

• Behavioral activation is a technique that recognizes that negative emotions are often tied to day-to-day interactions that involve few positive experiences. This technique intentionally and systematically increases the number of pleasant events the young person experiences. This system reinforces positive viewpoints about day-to-day interactions to replace the original negative beliefs. 

OTHER EVIDENCE-BASED TREATMENTS:

Multisystemic Therapy (MST)

Multisystemic therapy (MST) is a family-focused evidence-based intervention for youth displaying significant antisocial behaviors, delinquency, and substance problems. MST appraises these behaviors within the larger context, including the individual, family, peer, school, and community influences. MST interventions reduce antisocial behaviors and improve youth and family functioning.

Dialectical behavior therapy (DBT) for adolescents is an evidence-based treatment developed for suicidal, multi-problem adolescents. It has since been adapted for a broader range of adolescents who present with emotional and behavioral challenges. While DBT started as an outpatient psychotherapy intervention, it is utilized in clinical and non-clinical settings, including schools, residential facilities, and inpatient hospital settings. DBT integrates cognitive-behavioral, mindfulness/acceptance, biosocial, and dialectical approaches to treatment. Comprehensive DBT includes multi-family skills, individual DBT therapy, inter-session coaching via telephone/text, family therapy sessions/parenting sessions, and ongoing consultation with the treatment team. This approach has demonstrated effectiveness for bipolar disorders and the treatment of self-injury. 

Interpersonal psychotherapy (IPT) is a short-term treatment that is particularly effective in treating depression in adolescents and is based on the idea that depression occurs in the context of an individual’s relationships. The original IPT has been adapted for adolescents to address issues such as separation from parents, development of romantic relationships, and initial experience with the death of a relative or friend. IPT-A is typically a 12-to-16-week treatment. The therapy primarily involves individual sessions with the teenager and therapist. Parents participate in the first few sessions to receive education about depression and how to support their child through treatment. Numerous studies have proved IPT effective in treating depression in adolescents in both group and individual formats.

Motivational Interviewing (MI) is a therapeutic strategy that maintains that indecision is a normal reaction to treatment but is an obstacle to getting better. This technique focuses on client-therapist verbal communication and aims to foster an open dialogue that promotes internally motivated change in clients. This approach involves the client speaking more than the therapist. Moreover, the therapist's role is to listen to the client and provide empathy and optimism. The collaborative conversation is called "change talk."  The evidence suggests that Motivational Interviewing can effectively reduce substance use and other problematic behavioral issues. 

DISSEMINATION OF EVIDENCE-BASED TREATMENTS:

Mental health professionals who use evidence-based treatments are committed to offering the best level of care to their patients. A comprehensive discussion is provided in the curated listings and links below if you would like to become more informed about these approaches. While these resources are informative, becoming proficient in the application of these techniques requires supervision by professionals that have expertise in the respective approaches. 

As always, if you have questions about the behavioral health needs of your patients, we encourage you to call the BHIPP consultation line at 

855-MD-BHIPP (632-4477), open 9am-5pm Monday-Friday, for resource/referral networking or consultation support.

We will keep you informed about all our services and training events through our website (www.mdbhipp.org) and monthly e-newsletters. Additionally, BHIPP is on LinkedIn, Twitter, and Facebook. We invite you to follow us there to stay up-to-date on upcoming training events, pediatric mental health research, and resources for providers, families and children.



RECOMMENDED RESOURCES

• Anxiety and Depression Association of America (ADAA): https://www.adaa.org/
• Autism Speaks: https://www.autismspeaks.org/
• CHADD: http://www.chadd.org
• National Eating Disorder Association (NEDA): https://www.nationaleatingdisorders.org/
• Evidence-Based Behavioral-Practice (EBBP): http://www.ebbp.org/
• Families for Depression Awareness: http://www.familyaware.org/
• Info About Kids: http://infoaboutkids.org/
• International OCD Foundation: https://iocdf.org/
• National Federation of Families for Children’s Mental Health: http://www.ffcmh.org/

REFERENCES

Prinstein, Mitchell J., Eric A. Youngstrom, Eric J. Mash, and Russell A. Barkley, eds. "Treatment of disorders in childhood and adolescence." (2019).

BHIPP Announcements

Registration remains open for the BHIPP ECHO Clinic Beyond the Basics series; the next clinic is on 1/12 from 12:30-1:30 pm 

Registration is now open for the new BHIPP ECHO Clinic Core Foundations series which starts on 1/18 from 8:00-9:00 am 

Join us for the BHIPP Mental Health Crisis Training on 1/19 from 12:00-1:00 pm 

Read BHIPP's latest scientific publication!

BHIPP’s latest article Characteristics of Patients Served by a Statewide Child Psychiatry Acess program, examined the needs of pediatric patients in primary care served by BHIPP and was published in the American Psychiatric Association's Psychiatric Service Journal.

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