Emotional Disorders in Children and Adolescents. Medical and Psychological Approaches to Treatment

682 Pages·1980·12.605 MB·English

by  G. Pirooz Sholevar, Ronald M. Benson and Barton J. Blinder (Eds.)

EMOTIONAL
IIISORDERS
IN CHILDREN
AND
ADOLESCENTS
Medical and Psychological
Approaches to Treatment
Edited by
G. Pirooz Sholevar, M.D.
Clinical Professor and Director
Division of Child, Adolescent and Family Psychiatry
Thomas Jefferson University
Philadelphia, Pennsylvania
with
Ronald M. Benson, M.D.
Clinical Associate Professor and Director
Youth and Outpatient Services
Children's Psychiatric Hospital
University Medical Center
Ann Arbor, Michigan
and
Barton J. Blinder, M.D.
Clinical Associate Professor
Department of Psychiatry and Human Behavior
School of Medicine
University of California at Irvine
Irvine, California
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Contributors
JULES C. ABRAMS, M.D. IRVING H. BERKOVITZ, M.D.
Professor and Director of Graduate Senior Psychiatric Consultant for Schools
Education in Psychology Los Angeles County Department of Mental
Hahnemann Medical College and Hospital Health
Philadelphia, Pennsylvania and
Associate Clinical Professor
Child Psychiatry
PAUL L. ADAMS, M.D.
University of California at Los Angeles
Professor and Vice Chairperson
and
Department of Psychiatry
Member and Faculty Southern California
University of Louisville
Psychoanalytic Society-Institute
Louisville, Kentucky
Los Angeles, California
PAULA BRAM AMAR, Ph.D.
Clinical Assistant Professor BARTON J. BLINDER, M.D.
Department of Psychiatry and Human Clinical Assistant Professor
Behavior Department of Psychiatry and Human
Thomas Jefferson University Behavior
Philadelphia, Pennsylvania University of California at Irvine
Irvine, California
ASHLEY J. ANGERT, D.O.
Clinical Assistant Professor
HILDE BRUCH, M.D.
Department of Psychiatry and Human
Professor Emeritus of Psychiatry
Behavior
Baylor College of Medicine
Thomas Jefferson University
Houston, Texas
Philadelphia, Pennsylvania
and
Assistant Director
J. ALEXIS BURLAND, M.D.
Developmental Center for Autistic Children
Clinical Professor
Philadelphia, Pennsylvania Department of Psychiatry and Human
Behavior
RUSSELL S. ASNES, M.D. Thomas Jefferson University
Associate Professor of Clinical Pediatrics and
College of Physicians and Surgeons Philadelphia Psychoanalytic Institute
Columbia University Philadelphia, Pennsylvania
New York, New York
DENNIS P. CANTWELL, M.D.
JULES R. BEMPORAD, M.D. Professor
Director of Children's Services Department of Psychiatry
Associate Professor of Psychiatry University of California, Los Angeles
Massachusetts Mental Health Center School of Medicine
Harvard Medical School Los Angeles, California
Cambridge, Massachusetts
THEODORE B. COHEN, M.D.
RONALD M. BENSON, M.D.
Clinical Professor of Psychiatry and Human
Clinical Associate Professor and Director
Behavior
Youth and Outpatient Services
Thomas Jefferson University
Children's Psychiatric Hospital
Philadelphia, Pennsylvania
University Medical Center
Ann Arbor, Michigan
CHARLES W. DAVENPORT, M.D.
JOHN M. BERECZ, Ph.D. Associate Professor and Director
Associate Professor of Psychology Division of Child Psychiatry
Andrews University Medical College of Ohio
Berrien Springs, Michigan Toledo, Ohio
JOHN Y. DONALDSON, M.D. CHARLES JAFFE, M.D.
Associate Professor of Psychiatry Assistant Director
University of Nebraska Medical Center Adolescent Services
and Institute for Psychosomatic and Psychiatric
Clinical Director Research and Training
Children's/Adolescent Services Michael Reese Hospital and Medical Center
Nebraska Psychiatric Institute Chicago, Illinois
Omaha, Nebraska
RICHARD L. JENKINS, M.D.
MERRITT H. EGAN, M.D. Emeritus Professor of Psychiatry
Clinical Associate Professor of Psychiatry University of Iowa
College of Medicine Iowa City, Iowa
University of Utah
Salt Lake City, Utah. IRVIN A. KRAFT, M.D.
Clinical Professor of Psychiatry
RUDOLF EKSTEIN, Ph.D. Baylor College of Medicine
Clinical Professor of Medical Psychology Houston, Texas
University of California, Los Angeles and
and Clinical Professor
Training Analyst School of Public Health
Los Angeles Psychoanalytic Society and University of Texas Health Science Center
Institute Houston, Texas
and
Training Analyst RICHARD A. KRESCH, M.D.
Southern California Psychoanalytic Society Instructor in Clinical Psychiatry
and Institute Columbia University
Los Angeles, California College of Physicians and Surgeons
New York, New York
MILTIADES GEORGE EVANGELAKIS, and
M.D. Director of Psychiatry
Clinical Professor St. Mary's Hospital for Children
Department of Psychiatry Bayside, New York
School of Medicine
University of Miami CECILY LEGG, M.S.W., R.N.
Miami, Florida Children's Psychiatric Hospital
and University of Michigan
Director Ann Arbor, Michigan
Department Education, Training and
Research RONALD A. MANN, Ph.D.
South Florida State Hospital Assistant Clinical Professor in Psychiatry
Hollywood, Florida University of California at Los Angeles
Los Angeles, California
LINDA FEINFELD, M.D.
Clinical Assistant Professor FRANK J. MENALASCINO, M.D.
Department of Psychiatry and Human Professor of Psychiatry
Behavior University of Nebraska Medical Center
Thomas Jefferson University and
Philadelphia, Pennsylvania Associate Director
Nebraska Psychiatric Institute
STUART M. FINCH, M.D. Omaha, Nebraska
Department of Psychiatry
University of Arizona College of Medicine GILBERT G. MORRISON, M.D., Ph.D.
Tucson, Arizona Clinical Professor of Psychiatry and Child
Psychiatry
RONALD C. HANSEN, M.D. College of Medicine
Assistant Professor University of California, Irvine
Department of Pediatrics and
University of Arizona College of Medicine Supervisor and Training Psychoanalyst
Tucson, Arizona Southern California Psychoanalytic Institute
and Department of Psychiatry and Behavioral
Instructor in Psychoanalysis Science
Southern California Psychoanalytic Institute Stanford University School of Medicine
Los Angeles, California Stanford, California
GENE RICHARD MOSS, M.D.
BERTRUM A. RUTTENBERG, M.D.
Associate Clinical Professor in Psychiatry
Professor
University of Southern California
Department of Psychiatry and Human
Los Angeles, California
Behavior
Thomas Jefferson University
HUMBERTO NAGERA
and
Director of the Child Analytic Study
Director
Program
Developmental Center for Autistic Children
Chief of the Youth Service
Philadelphia, Pennsylvania
Department of Psychiatry
University of Michigan Medical School
Ann Arbor, Michigan CHARLES A. SARNOFF, M.D.
Lecturer
DANIEL OFFER, M.D. Columbia University
Chairman College of Physicians and Surgeons
Department of Psychiatry Psychoanalytic Center for Training and
Director Research
Institute for Psychosomatic and Psychiatric New York, New York
Research and Training
Michael Reese Hospital and Medical Center
CHARLES E. SCHAEFER, Ph.D.
and
Supervising Psychologist
Professor of Psychiatry
The Children's Village
Pritzker School of Medicine
Dobbs Ferry, New York
University of Chicago
Chicago, Illinois
RODNEY J. SHAPIRO, M.D.
THEODORE A. PETTI, M.D. Director
Assistant Professor of Child Psychiatry Family and Marriage Clinic
Program Director Associate Professor of Psychiatry and
Children's Psychiatric Intensive Care Service Psychology
Western Psychiatric Institute and Clinic Department of Psychiatry
University of Pittsburgh University of Rochester Medical School
Pittsburgh, Pennsylvania Rochester, New York
DONALD B. RINSLEY, M.D.
G. PIROOZ SHOLEVAR, M.D.
Clinical Professor of Psychiatry
Clinical Professor and Director
University of Kansas School of Medicine
Division of Child, Adolescent and Family
and
Psychiatry
Associate Chief for Education, Psychiatry
Jefferson Medical College
Service
Thomas Jefferson University
Topeka Veterans Administration Medical
and
Center
Hahnemann Medical College and Hospital
and
Philadelphia, Pennsylvania
Senior Faculty Member, Adult and Child
Psychiatry
Menninger School of Psychiatry MOISY SHOPPER, M.D.
Topeka, Kansas Clinical Associate Professor of Child
Psychiatry
ALAN J. ROSENTHAL, M.D. St. Louis University
Director School of Medicine
Children's Health Council and
Palo Alto, California Faculty
and St. Louis Psychoanalytic Institute
Clinical Associate Professor of Psychiatry St. Louis, Missouri
IM. DUNCAN STANTON, Ph.D. Association for Jewish Children of
Associate Professor of Psychology Philadelphia
Department of Psychiatry Philadelphia, Pennsylvania
University of Pennsylvania School of
Medicine
JAMES M. TOOLAN, M.D.
and
Assistant Professor of Clinical Psychiatry
Director
University of Ven îont
Addicts and Families Program
Burlington, Vermont
Philadelphia Child Guidance Clinic
and
and
Consulting Psychiatrist, Marlboro College
Director of Family Therapy
Marlboro, Vermont
Drug Dependence Treatment Center
Philadelphia VA Hospital
Philadelphia, Pennsylvania ROBERT G. WAHLER, Ph.D.
Professor and Director
Child Behavior Institute
JOHN A. SOURS, M.D.
University of Tennessee
Clinical Assistant Professor of Psychiatry
Knoxville, Tennessee
College of Physicians and Surgeons
Columbia University
and DAVID ZINN, M.D.
Supervisor and Training Psychoanalyst Director of Adolescent Services
Columbia Psychoanalytic for Training and Clinical Assistant Professor
Research University of Chicago
and Chicago, Illinois
Supervising Child Psychoanalyst
New York Psychoanalytic Institute
JOEL P. ZRULL, M.D.
New York, New York
Professor and Chairman
Department of Psychiatry
JOSEPH L. TAYLOR, ACSW Medical College of Ohio
Executive Director Toledo, Ohio
CHAPTER 1
Individual Psychotherapy
Paul L Adams
Individual Psychotherapy seen by a therapist. The term does not say what
they do together, nor does it set any limits on what
Unique Skill they may do. It is like the Zen sign in the post
office: the postmaster is neither required to give
There is nothing more specific, more intrinsic, to change for bills, nor authorized to refuse. Take
treatment of emotional disorders in children than your chances and hope for the best.
individual psychotherapy. It is the novelty that Critics of individual psychotherapy are legion.
must be contended with by anyone who attempts Some denounce it as a fruitless expenditure of time,
to function well in the field of child treatment. It energy and money. Some contend that since it is
is the acid test for someone who can "make it" in not of universally proven efficacy in unselected
being helpful and therapeutic with children. We can cases, it is no better than the passage of time and
take family histories, perform physical examina- the evolution of the natural history of emotional
tions, order laboratory studies, dispense drugs ap- crises in the human cycle of experienced stresses
propriate to a child's weight and needs—all on the and problems. Some see it as dangerous from a
basis of earlier acquired skills and knowledge. Al- political standpoint because it questions both in-
most everything else we do in child psychiatry is dividual and societal status quo. Some have phil-
derivative or modified from psychiatric work with osophic objections, claiming that it is not a suitable
adults. Only in individual psychotherapy do we endeavor for mass society, where normlessness,
glimpse what is radically new and different: that alienation and loneliness are the major facts of life,
sharp demarcation between the state of the child problems that are not readily soluble by individual
and the state of the adult. A truly skillful therapist verbal therapy. Some point out that all therapies
can work with a whole range of ages, perhaps, all do some good, have some ameliorative conse-
across the life cycle, but the singular epoch to test quences on suffering, but that one type is about as
the mettle of the attending therapist is childhood. good as another, and that proves, they say, that no
And therapy with the individual child is a unique claims can be made for any particular type of
art and craft. There is even some promise of semi- therapy (Eysenck, 1966).
scientific work and study looming in the future. Ford and Urban (1964) concluded that individual
verbal psychotherapy is done when two people get
together, interacting (mainly by talking) in a pro-
Terminology longed series of emotionally charged encounters,
with the whole intent being one of changing the
"Individual psychotherapy" is a nonspecific la- behavior of one of the dyad. That is a good enough
bel. The terms tells us only that one child is being summation of what it is that happens in individual
3
4 ADAMS
child therapy, too, it would seem. It is largely a sonal, humanistic, and comprehensive pyramid of
talking cure—dialogue about dreams and wakeful dynamics. Maslow's scheme encompassed Marxian,
experiences—although selected times may be given Freudian, Sullivanian, Adlerian, and other systems
over to play, to role-taking, to walks, to eating of psychodynamics, adding some of the optimism
together, to caressing and holding, and perhaps of Rousseau as to human fulfillment and perfecti-
even to massage. In Norway, under the influence of bility. Maslow added at the peak of his epigenetic
Nik Waal, a Reichian analyst, it is quite acceptable pyramid, self-actualization, a term derived from
for a child guidance clinic therapist to undertake Kurt Goldstein and now widely adopted by hu-
massage and muscle palpation in the interest of manistic psychologists of many and varied stripes.
"vegetotherapy," and yet to make the main burden
of the therapy one that is carried forward verbally.
Individual therapy as it is discussed in this chap-
Caveat Concerning Context
ter is the kind of therapy that is verbal, dynamically
oriented but adaptable to short and medium terms
In this discussion of the individual child in direct
of time and effort. That is, it is practicable in child
psychotherapy some risky assumptions may seem
psychiatry clinics, child guidance clinics, child-and-
to be made. For example, it may erroneously be
family agencies, and community mental health
concluded that the only sensible and effective way
programs, as well as in private consulting rooms.
is to work with one child alone. In reality, that
It may be that this kind of individual therapy can
assumption is not made. The present task, sacrific-
be employed along with, or in series with, child
ing but not forgetting completeness, is to try to
analysis, behavior therapy, crisis intervention,
make as many rational statements as can be made
group therapies, and other modalities. It is not
in a brief chapter about what transpires when one
altogether certain that the form of individual ther-
works directly with a child. But that is not to say
apy described in this chapter is fully compatible
nor to imply that no other work needs to be done.
with all these other forms, but it does seem likely.
At times, work with children in groups is impor-
tant, and most of the time work with family groups
is essential. Collaborative work, alongside a col-
Dynamisms and Motives in Individual
league who sees the parents, is a tried and true
Psychotherapy
procedure in child guidance and child therapy. In
what is said on the topic of direct work with the
Insight-oriented psychotherapy takes very seri-
single child, it may appear that a message is being
ously the question why and the question how.
sent that context can be ignored when we dwell on
Causation of behavior, the précipitants and triggers
one child and his inner world. Far from that: a full
of behavior, the remote genesis of behavior, the
awareness of the larger context is a virtue, an aid,
driving force, reinforcers and punishers, the motive
and an adjunct to individual psychotherapy with
power—all are important in individual verbal psy-
the child. Only when we can see the child and the
chotherapy between adult and child. Yet these are
therapy in a fuller biocultural milieu—and make
diverse schools. Some therapists may rely fully on
the outer world explicit, too—do we commence
the general orthodox Freudian dynamisms of Eros
being truly of aid and comfort to distressed young
and Thanatos, while others may not be able to
children.
swallow the death instinct and will substitute
aggression for it (Brenner, 1955). Horneyans will be
content with basic anxiety about love loss (and-
History
anxiety-influenced patterns of moving toward,
moving away from and moving against others) as
the wrap-up of motivation. Adlerians will stress The history of individual child psychotherapy is
the desire to move into a "relative plus" position enwrapped with a diversity of social developments
in one's self-esteem as well as becoming relatively and intellectual movements which are child-fo-
more competent and sociable in one's interpersonal cused. The history of child psychotherapy is the
dealings. Sullivanians point out the primacy of subject of a forthcoming publication by Professor
dynamics referable to the child's wish for gratifi- John F. Kenward (1977) of the University of Chi-
cation of animal needs, as well as its needs for cago, which will give a more judicious assessment
security and comfort interpersonally. Maslow (1943) of the fuller story. Articles by Crutcher (1943),
developed a more complicated and a more per- Harms (1960), Selesnick (1965), Anthony (1973),
INDIVIDUAL PSYCHOTHERAPY 5
Kanner (1973), and de Mause (1975) will be helpful movements, from Otto Rank's influence on therapy
to the interested student in the meantime. and functional casework, from the support given
It will suffice to point out now that individual to child psychiatry within medical schools, from
child therapy is eclectic or pluralistic and has a the new humanistic field of psychohistory, from the
diversified heritage—in the work of educators, non- so-called kiddie lib movement (for civil liberation
participant child watchers, participant observers of of children), but alas, hardly anything at all from
children, psychometrists, reformers, pediatricians, the NIMH-fostered community mental health
norm-finding surveyors of customs and opinions, movement. Recently the field of child therapy has
revolutionaries, psychoanalysts, social scientists, begun to derive as much as it has given to such off
social workers, legal scholars, and behavioristic beat developments as humanistic therapy, growth
psychologists. Probably others have played a vital or human potential gatherings, transactional anal-
role in the development of dynamically oriented, ysis, Gestalt therapy, and other trends included
ego-centered, verbal psychotherapy with one child. under Maslow's "Third Force" rubric. Many of
But it is a proud heritage that started with John these are dealt with in sections devoted to therapy
Amos Comenius, a Moravian bishop uprooted by in the Basic Handbook of Child Psychiatry (Nosh-
the Thirty Years' War who was an apostle of kind- pitz et al., 1979).
ness and permissiveness in educating and encultur- Multiple historical roots can be traced for a
ating children. Comenius was a refugee, too, from flexible, eclectic, or pluralistic type of dynamover-
religious persecution in Bohemia; so from this bal psychotherapy that values highly the life and
beginning on, humaneness with children seems destiny of one small child. Some of this converging
repetitively bound up with liberation movements. multiplicity and diversity is discernible in the as-
Lacking, however, from later longings for justice sumptions that underlie the therapy I shall describe.
are the colorful phrasings of Comenius, the beauty
of Moravian music, the joyous simplicity of the
Eastertime love feast, and the whole pietistic spirit Axioms and Assumptions
of German Protestantism.
Sustenance for positive valuations on children In science, facts are tested statements about
during the last two centuries flowed over from the observed events and relationships. Theories are
liberal, anti-monarchical or anti-totalitarian phi- systems of facts, more general, but still statements,
losophers; from the movement against slavery; however, that correspond to replicable, consen-
from the movement to protect domestic animals sually validated experience. When theories become
against cruel treatment (here the spin-off was direct, so well accepted because they are highly useful or
for children were first protected in the United simply earn the status of being statements to which
States against cruel beatings on the grounds that most sensible people do not take exception, theories
they were animals after all [Kahn, 1963]); from the drop out of the spotlight and come to be taken for
movement to end child labor, to provide free edu- granted. Hence, theory merges into the realm of
cation for all (and to test IQ); from the women's axioms, undisputed facts, implicitly held assump-
movement to obtain equality and justice regardless tions. Thereafter, only new hypotheses can call
of gender; from the workers' movement for social- facts and theories out of the shadows.
ism or economic equality, whereby no person was Now, psychotherapy is not scientific yet, but it
given special advantage based on inherited great is so much an art that its footing as a secure craft
wealth; from the Heilpaedogogik movement (special is not always earned. Still, there are certain as-
or remedial education); from the psychoanalytic sumptions not commonly spelled out—axioms—
movement, even if psychoanalysis came to scorn that underlie individual verbal psychotherapy with
direct social action and to set itself up as a substi- one child and one adult. Undoubtedly, there would
tute for social action (seeing itself as an ethical be disagreement and controversy about the most
culture substitute for the neurotic excesses of so- careful and judicious statement of these axioms. If
cialism, democracy, Judaism, and Christianity for no other reason, we object to any critique,
[Fromm, 1959]), and most particularly from child articulation, and formulation of our axioms be-
analysis, Hermione von Hug-Hellmuth, Anna cause it is "nicer" to leave axioms unsaid, unstated,
Freud, Melanie Klein, and the followers of the sacred.
latter two. In the United States during the twentieth 1. The first axiom underlying individual psycho-
century additional sustenance for child therapy has therapy is that a child is a person of value. Some
come from the child guidance and mental hygiene groups of people in our era and masses of people
6 ADAMS
in milieus and epochs different from our own have of guides for psychotherapy, even if the therapist is
not valued children positively. That puts it mildly. nonmedical. Values on confidentiality, respect,
When people do not want to serve and supply moral rectitude, professional constraints, and en-
children with resources they need, people will not deavors (with eclecticism and empiricism) to do
do psychotherapy. Instead, they will work for and anything that is honorable to be of use to the
with adults exclusively, even to a child's detriment, patient—all are values that undergird both medi-
for they find children to be gross, immature, weak, cine and the kind of child psychotherapy I am
and too crudely incipient, too inexperienced. considering. The reader will note that this is in
2. A second axiom underpinning this kind of strong contradistinction to Sigmund Freud's con-
therapy is that a child depends on adults to provide tentions that lay analysis is superior to medical
security to the child. Children are consumers of analysis, or that a therapist should not touch the
security, both economic and mental, and if a child body of his analysand, and so on.
is lucky, the fundamental unit for giving and re-
ceiving security is the family unit.
Limits on Applicability
3. Adults can communicate with children; they can
have empathy for children. Adults have been chil-
dren and can reach back across the chasm of A therapy mode that is marked by diversity, is
forgetting and repression to the times when they pluralistic and flexible, and relies basically on the
lived in a sensorimotor, prelogical cognitive stage. help that comes through dialogue, through sharing
It is a sign of maturity and mental health, and of one's humanity with an imaginative other per-
above all of therapeutic skill, if an adult is able to son, does not have too many areas where it is not
be childlike in imagination and thereby establish of some helpfulness to unhappy children. Nonethe-
warm rapport with a young child. less, there are some therapy prospects that are
4. Talking is an important vehicle for interpersonal considerably more auspicious, relatively speaking.
relatedness. Distinctively human, speech allows us These must be stated, along with the relatively
to project ideas and feelings from one cerebral unfavorable traits. Limits (some of which may be
cortex to another. In talking with one another, we needlessly so) include age of child, developmental
can hurt and insult, or we can bring healing help. stage, IQ, gender, class, ethnicity, family type, di-
Hence the talking cure becomes a possibility for agnostic grouping, ego strengths, physique, tem-
child-adult relations. perament and id strengths.
5. Early intervention is preferable; preventive The child under five years of age is not an ideal
work is superior to remedial and rehabilitative candidate for this general therapy approach, and
work. Childhood presents us with an opportunity responds better to more play, less talk, and more
to do early intervention and to turn the course of concentrated work through the parents. An alter-
the blighted life cycle around toward health. native way of putting this and some subsequent
6. Problematic behavior can be changed. The bio- ideas would be not to emphasize the child's lacks,
logic foundations given by heredity may be durable and to put more of the onus for limitations on the
and nearly immutable, but the behavior of an adults, the therapists. In sum, our frailties are not
individual is subject to reinforcers and extinguish- to be projected as the child's faults and deficiencies.
ers, and is relatively malleable. Developmental stage is limiting whenever the
7. All behavior loses some of its weirdness when it child is far behind his expected stage of develop-
is understood in its existential context. The context ment—that is, in comparison to his chronologic
must be specified if the behavior is to be rendered age. Low IQ—below 70, for example—generallly
understandable and alterable. makes the work more difficult. Also, ego strengths
8. It is easier to augment competent acts than to that are impaired set up obstacles to the usefulness
diminish defective behavior. Behaviorists and Ran- of this general type of therapy. Specifically, handi-
kians join the majority in stressing the positive caps in perception, in intellection, and in conation
aspects of a child's behavior (Saslow, 1975; Allen, impede therapeutic success (Murray and Kluck-
1963). hohn, 1954). Obversely, intactness of reality testing,
9. When a child's behavior is healthier, the child judgment, sense of reality, regulation and control
will also feel better and think better. Therapy has of drives, object relations, thought processes, adap-
affective, cognitive, and behavioral effects. Therapy tive regression in the service of the ego, defensive
is both rational and humanistic. functioning, stimulus barrier, autonomous func-
10. Medical ethics and practice provide a system tioning, synthetic and integrative functioning, and