Efficacy of Dialectical Behavior Therapy for Adolescents in a Partial Hospitalization Program

This study evaluated dialectical behavior therapy for adolescents (DBT‐A) vs. treatment as usual within a 6‐week partial hospitalization program. The 103 adolescent participants (mean age = 15.27 years) were predominantly girls (n = 63, 61%) with a variety of primary mental health diagnoses. Results indicated that DBT‐A was superior for decreasing symptoms of depression and interpersonal sensitivity, but no statistically significant difference was detected for anxiety or hostility. Implications for treating youth with transdiagnostic identities are discussed.     

Transdiagnostic Theory and Application of Family-Based Treatment for Youth with Eating Disorders

This paper describes the transdiagnostic theory and application of family-based treatment (FBT) for children and adolescents with eating disorders. We review the fundamentals of FBT, a transdiagnostic theoretical model of FBT and the literature supporting its clinical application, adaptations across developmental stages and the diagnostic spectrum of eating disorders, and the strengths and challenges of this approach, including its suitability for youth. Finally, we report a case study of an adolescent female with eating disorder not otherwise specified (EDNOS) for whom FBT was effective. We conclude that FBT is a promising outpatient treatment for anorexia nervosa, bulimia nervosa, and their EDNOS variants. The transdiagnostic model of FBT posits that while the etiology of an eating disorder is unknown, the pathology affects the family and home environment in ways that inadvertently allow for symptom maintenance and progression. FBT directly targets and resolves family level variables, including secrecy, blame, internalization of illness, and extreme active or passive parental responses to the eating disorder. Future research will test these mechanisms, which are currently theoretical.     

Adolescent non-suicidal self-injurious behavior: The latest epidemic to assess and treat

Non-suicidal self-injury (NSSI) among adolescents is a serious and prevalent problem. This article reviews the epidemiological data as well as the existing treatments for adolescents who engage in NSSI. The authors also present the unique features of dialectical behavior therapy, the gold-standard evidence-based treatment for adults who engage in NSSI, and discuss its promise as an effective treatment for adolescents who engage in NSSI. Finally, the authors present a clinical vignette of an adolescent engaging in NSSI and how DBT works to target this maladaptive behavior.This article reviews first the epidemiological data and then the existing treatments for adolescents engaging in non-suicidal self-injurious behavior (NSSI). Next, the authors present the unique features of one particular therapy, called dialectical behavior therapy, for adolescents who engage in NSSI. Finally, the article concludes with a clinical vignette in which dialectical behavior therapy is applied to an adolescent engaging in NSSI.     

Dialectical Behavior Therapy Modified for Adolescent Binge Eating Disorder: A Case Report

Given the lack of empirically supported treatments available for adolescents with eating disorders, it is important to investigate the clinical utility of extending treatments for adults with eating disorders to younger populations. Dialectical behavior therapy for binge eating disorder, based on the affect-regulation model, conceptualizes binge eating as a behavioral attempt to influence, change, or control painful emotional states. With promising research findings in adult women, it is of clinical interest whether the dialectical behavior therapy for binge eating disorder treatment manual could be usefully adapted for an adolescent population. This report describes adolescent-specific modifications (including the use of family sessions) to standard dialectical behavior therapy for binge eating disorder, with an illustrative case study. While more rigorous case studies are needed prior to establishing justification for a randomized trial, this pilot case provides preliminary support for a modified version of dialectical behavior therapy for binge eating disorder as a therapeutic option for adolescents with binge eating disorder.     

Targeting Common Factors Across Anxiety and Depression Using the Unified Protocol for the Treatment of Emotional Disorders in Adolescents

Clinical approaches to mood and anxiety disorders in children and adolescents have historically been confined to either diagnosis- [e.g., for obsessive–compulsive disorder vs. generalized anxiety disorder (GAD), etc.] or domain-specific (e.g., for anxiety disorders vs. depressive disorders) treatments. However, as conceptualizations of mental illness shift towards a more dimensional model [e.g., the recent Research Domain Criteria (RDoC) from the National Institutes of Health], transdiagnostic treatments, such as the unified protocol for the treatment of emotional disorders in adolescents (UP-A; Ehrenreich et al. in Child Fam Behav Ther 31(1):20–37, 2008), are gaining support in the empirical literature. This paper reviews the common treatment targets across three emotional disorders commonly found in adolescence: GAD, social anxiety disorder, and major depressive disorder. In particular, similarities and differences across potential treatment mechanisms, including cognitive and information processing deficits, problem-solving difficulties, and avoidance strategies are examined. Finally, the case of 17-year-old “Andrea” is presented to demonstrate how transdiagnostic approaches like the UP-A can be effective in treating a range of emotional disorders in youth.     

Standing between two worlds in Harlem: A developmental psychopathology perspective of perinatally acquired human immunodeficiency virus and adolescence

Perinatal HIV infection in the US continues to evolve from a fatal pediatric illness to a chronic medical condition of childhood and adolescence. Although navigating this period is influenced by multi-leveled deprivations commonly experienced by low-income minority families, HIV alters the timing and experience of developmental milestones for many adolescents with perinatal HIV. This selective review of the growing developmental psychopathology literature and the authors' clinical work at a pediatric HIV program in Harlem, NY provide an overview of how developmental psychopathology offers an integrative framework that elucidates how autonomy, peer relationships, and self-concept evolve among 13–21 year old adolescents. This paper highlights the importance of considering influences of both perinatal HIV and the culture of poverty on adolescent development, and of adopting multilevel interventions and research to address how interactions among biologic, environmental, and HIV-related stressors (serostatus disclosure, medical treatment adherence, illness stigma) influence the development of adolescents with perinatal HIV.     

Reward Dysregulation and Mood Symptoms in an Adolescent Outpatient Sample

Research on bipolar spectrum disorders (BPSD) in adolescence has burgeoned in the last decade, but continued work is needed to identify endophenotypic markers associated with illness onset and course. The present study examined reward dysregulation—measured via the behavioral activation system (BAS)—as one putative marker of BPSD in adolescence. A diverse group of 425 outpatient adolescents between 11 and 17 years of age (52 % male) completed the Behavioral Inhibition and Activation Scale (BIS-BAS) scale to measure reward dysregulation. Semi-structured interviews determined diagnoses and severity of mood symptoms. Parent-reported BAS was associated with increased symptoms of mania, and parent and adolescent-reported BAS were associated with symptoms of depression. Parent-reported BIS scores were associated with increased symptoms of mania. Results held independent of diagnostic status. Furthermore, parent BIS/BAS reports were stronger predictors for manic symptoms compared to adolescent-reports. Results extend work in adults with BPSD, suggesting a transdiagnostic association between reward dysregulation and mood symptom severity in adolescence.     

Using the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders With Youth Exhibiting Anger and Irritability

The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Children and Adolescents (UP-C and UP-A) are evidence-based treatment programs with cognitive-behavioral and third-wave behavior therapy elements, aimed at extinguishing distress to intense emotion states and reducing unhelpful action tendencies in such states among youth with emotional disorders. A growing body of literature demonstrates the high prevalence of problematic anger and irritability among youth with emotional disorders, yet evidence-based treatments to address anger and irritability are typically developed more exclusively for youth with externalizing disorders. Given this need, a clinical case example of the UP-C applied to a child with anger and irritability is presented. Application of transdiagnostic theory to both conventional anxiety concerns and to irritability concerns is discussed. We demonstrate the flexibility and utility of a transdiagnostic approach like the UP-A and UP-C for addressing concerns across a range of emotions.     

When adolescents "mismanage" their chronic medical conditions: an ethical exploration

Many adolescent patients with chronic medical conditions do not manage their illnesses very closely and often put themselves at risk for serious health complications. Setting aside cases of nonadherence that are due to practical difficulties involving the implementation of a management plan, a deeply problematic question remains. How should health care providers respond to adolescent patients who express a conscious and value-driven decision to pursue other goals and interests that are incompatible with their doctors' recommended directives? Using two guiding ethical principles, the "relevant difference principle" and the "principle of noninterference," as well as available empirical data on adolescent decision making and risk perception, the paper concludes that most adolescents ages 14 and older should be allowed to make self-determining decisions regarding the management of their chronic medical conditions.     

Maternal Emotion Socialization of Adolescent Girls Engaging in Non-Suicidal Self-Injury

Research on Child and Adolescent Psychopathology - Non-suicidal self injury (NSSI) is a transdiagnostic maladaptive behavior that is highly prevalent in adolescence. A greater understanding of the...     

Measuring Adherence to Medical Treatments in Childhood Chronic Illness: Considering Multiple Methods and Sources of Information

Adherence to medical treatment is a significant problem for children and adolescents with chronic conditions, such as asthma, diabetes, and cystic fibrosis. The consequences of nonadherence can be serious, contributing to increased symptoms, unnecessary hospitalizations, and declines in physical functioning. The quality of data obtained from clinical trials can also be affected by poor adherence, leading to erroneous conclusions concerning the efficacy of drug treatments and the dosages that are needed to achieve those effects. Adherence problems in both clinical research and practice also lead to substantially higher health care costs. In order to further our understanding of the barriers that lead to poor adherence and identify strategies that are effective in addressing them, we need to develop reliable and valid measures of adherence behaviors. Using cystic fibrosis as a model of a serious, chronic disease that requires a difficult and time-consuming medical regimen, three different types of adherence measures are considered: self-report questionnaires, daily diary reports, and electronic monitors. The specific advantages and disadvantages of each type of measurement are reviewed, and specific recommendations are made for future research.     

Anorexia Nervosa in Adolescence and Maudsley Family‐Based Treatment

Anorexia nervosa is a serious psychiatric disorder that usually occurs in adolescence. The course of the illness can be protracted. Current empirical evidence suggests that the Maudsley Family‐Based Treatment (MFBT) is efficacious for adolescents. MFBT empowers parents as a crucial treatment resource to assist in their child's recovery. The authors review the diagnostic criteria and course of anorexia in adolescence, present empirical evidence and key theoretical concepts of MFBT, and provide a case study.     

Examining Hope as a Transdiagnostic Mechanism of Change Across Anxiety Disorders and CBT Treatment Protocols

Hope is a trait that represents the capacity to identify strategies or pathways to achieve goals and the motivation or agency to effectively pursue those pathways. Hope has been demonstrated to be a robust source of resilience to anxiety and stress and there is limited evidence that, as has been suggested for decades, hope may function as a core process or transdiagnostic mechanism of change in psychotherapy. The current study examined the role of hope in predicting recovery in a clinical trial in which 223 individuals with 1 of 4 anxiety disorders were randomized to transdiagnostic cognitive behavior therapy (CBT), disorder-specific CBT, or a waitlist controlled condition. Effect size results indicated moderate to large intraindividual increases in hope, that changes in hope were consistent across the five CBT treatment protocols, that changes in hope were significantly greater in CBT relative to waitlist, and that changes in hope began early in treatment. Results of growth curve analyses indicated that CBT was a robust predictor of trajectories of change in hope compared to waitlist, and that changes in hope predicted changes in both self-reported and clinician-rated anxiety. Finally, a statistically significant indirect effect was found indicating that the effects of treatment on changes in anxiety were mediated by treatment effects on hope. Together, these results suggest that hope may be a promising transdiagnostic mechanism of change that is relevant across anxiety disorders and treatment protocols.     

Family Therapy with Unmarried African American Mothers and Their Adolescents

Almost two-thirds of African American births are to unmarried mothers, and these single parents are among the most economically vulnerable in the United States. The effects of chronic stressors such as poverty can compromise the ability of these mothers to parent effectively, particularly during the developmental period of adolescence, typically a stressful phase of parenting. This article describes a multidimensional family therapy (MDFT) approach to working with African American adolescents who have drug and/or behavior problems. It is maintained that addressing the intrapersonal functioning of African American single mothers is vital if they are to re-establish the attachment bonds necessary for the maintenance of essential parental influence in the lives of their adolescents. Through systematic attention to the parent as an individual, leading to a balance between self-care and care for others, parental supervision is more easily achieved and relational impasses between parent and adolescent more equitably resolved.     

Clinical Guidelines for Improving Dialectical Thinking in DBT

Cognitive dysregulation, often characterized by extreme, nondialectical thinking, is a core problem area identified in dialectical behavior therapy (DBT) and is posited to contribute to pervasive emotional and behavioral dysregulation. However, cognitive flexibility is understudied and rarely considered a direct treatment target in DBT. This paper provides clinical guidelines for increasing dialectical thinking with patients in DBT. We review the historical context of dialectical thinking in DBT and present the results of a survey examining DBT therapists’ perspectives on nondialectical thinking as a treatment focus. We describe cognitive restructuring strategies from cognitive therapy models, and compare these with techniques targeting cognitive dysregulation in DBT. We highlight the rationale for incorporating dialectical thinking as a direct treatment focus in DBT, and offer strategies derived from cognitive restructuring to incorporate directly targeting dialectical thinking in conceptualization, treatment planning, and in session. These strategies are demonstrated with clinical vignettes and examples.     

Comorbidity and Internet-Delivered Transdiagnostic Cognitive Behavioural Therapy for Anxiety Disorders

Internet-delivered transdiagnostic anxiety interventions aim to reduce symptoms across several anxiety disorders using one treatment protocol. However, it is unclear whether comorbidity affects outcomes of such treatment. This study re-examined data from a recent randomised controlled trial (N = 129) that evaluated the efficacy of an Internet-delivered transdiagnostic cognitive behavioural therapy (iCBT) intervention for participants with principal diagnoses of generalised anxiety disorder (GAD), social phobia (SP) panic disorder and agoraphobia (PDA), of whom 72% met criteria for a comorbid anxiety disorder or depression. Participants were divided into two groups based on whether or not they had a comorbid disorder before treatment. Participants with comorbid conditions reported higher symptom levels at pre-treatment, post-treatment, and follow-up across a range of measures. Both groups showed significant reductions in symptoms over treatment; however, participants with comorbid disorders showed greater reductions in measures of GAD, PDA, SP, depression, and neuroticism. In addition, treatment significantly reduced the number of comorbid diagnoses at follow-up. These results indicate transdiagnostic iCBT protocols have the potential to reduce comorbidity.     

Concepts of health and illness: different constructs or variations on a theme?

Although health and illness concepts are thought to be important mediators of health and illness behaviors, little work has been done examining health concepts, and no research has examined the two conceptual structures simultaneously. This study examined concepts of health and illness in 218 adolescents between the ages of 11 and 18 years. Results were consistent with the hypothesis that concepts of health and illness are not opposite ends of a single health dimension, but reflect different and overlapping constructs. The degree of overlap varied as a function of age, with health concepts showing less emphasis on "the absence of illness" with greater maturity. The results suggest that models of health behavior that focus on illness avoidance neglect many components of health salient to lay persons.     

Evaluating Attributions for an Illness Based Upon the Name: Chronic Fatigue Syndrome, Myalgic Encephalopathy and Florence Nightingale Disease

In recent years, considerable discussion has occurred about stigma surrounding the name given to an illness currently known as chronic fatigue syndrome (CFS). Although patients and medical personnel have expressed varying opinions on this issue, no studies have evaluated how beliefs about the illness change based upon the type of name used for diagnostic purposes. Proposals have been put forth to rename the illness with an eponym (a famous patient's or researcher's name) or with a less trivial sounding, more medically based type of name. In this study, attributions about CFS were measured in three groups of medical trainees. All groups read the same case study of a person with classic symptoms of chronic fatigue syndrome, with the only difference being in the type of name given. Trainees then were asked to provide attributions about certain aspects of the illness, including its cause, severity, and prognosis. Results suggested that, across name conditions, most trainees appeared to consider the symptom complex of CFS a serious illness resulting in poor quality of life. In addition, findings indicated that the name, chronic fatigue syndrome, may be regarded less seriously than the Myalgic Encephalopathy name with respect to some important aspects of the illness. In this study, specialty of medical trainee also played a role in how the illness was perceived.     

Implementation of a Trauma-Specific,Evidence-Informed Treatment for Adolescents: Two Cases Highlighting How to and How Not to Integrate

The clinical team at an urban trauma clinic sought to evaluate a protocol representing an integration of empirically validated treatment components to address trauma sequelae among female adolescents with a history of physical and/or sexual abuse. PARTNERS with teens is an exposure-based, trauma-specific cognitive-behavioral therapy protocol. Specifically, PARTNERS integrates engagement strategies, cultural sensitivity, and elements of motivational interviewing, dialectical behavior therapy, and family-based parent and communication training in order to reduce symptoms of posttraumatic stress disorder (PTSD) and depression and improve affect regulation among economically disadvantaged, multiracial/ethnic adolescents. This paper describes two cases that represent both treatment success and failure in treatment integration, specifically in negotiation of caregiver resistance, adolescent safety concerns, and ongoing interpersonal crises. Results illustrate how treatment components were emphasized and incorporated differentially throughout treatment as a function of case conceptualization. Successful implementation of treatment resulted in reductions in PTSD, depression, externalizing behaviors, and emotion dysregulation. In contrast, failure to effectively reconcile different philosophies and techniques within the treatment model to address challenges in engagement and motivation, inconsistent caregiver involvement, and trauma-related conflicts in the dyad, contributed to disengagement from treatment and persistence of trauma sequelae. Treatment outcome across these two cases is discussed as a function of how well the philosophies and techniques of different adolescent specific treatment components are integrated; directions for future research and training are discussed.