Oferta de Unión Temporal Centros Poblados Colombia 2020

Deriving practical applications of developmental research for clinical practice with children is, as has been repeatedly noted, no straightforward task. Nev-ertheless, thisfinal sectionconsiders some practical lessons from the preceding discussion and highlights how clinic-based research may play an especially impor-tant role in advancing theory.

3.5.1 Assessment, treatment and prevention

If there were cognitive preconditions to effective CBT, then it would be pos-sible to develop a screening measure that would identify those children likely to respond to this form of treatment. Similarly, if the contextual factors that impeded CBT were known, then it would be a reasonably straightforward task to distinguish those children most likely to respond to the comparatively brief treatment delivered within a standard CBT framework. Unfortunately, despite many years of CBT practice with children, there is only limited progress on these two fronts. Consequently, recommendations for the clinic setting are necessarily speculative. Nonetheless, some speculations are provided.

We take as a starting point that there is a need to ascertain, as early as possible in the course of clinic contact, an assessment of the likelihood of treatment failure versus treatment success. The twin themes developed in this chapter are a consideration of the child’s social cognitive sophistication and the child’s context.

As for the former, there are no clear indicators of treatment success. It is important to rule out some of the more obvious candidates, however. Thus, assessment of basic language and intellectual skills using traditional cognitive assessments may be important, particularly if there are doubts about the appropriateness of CBT because of, for example, the child’s age. However, standardized tests assess only very broad intellectual abilities and may not be sensitive to the kinds of cognitive processes tapped by CBT.

Of the more specific kinds of social cognitive assessments available, those developed by Dodge and colleagues cited above seem applicable. Measures of the older child’s emotional understanding, reflective capacity and ability to use mental states of self and other have not been systematically developed, but may be worth exploring. There is, for example, evidence from several sources that interview-based measures seem to work well from around 8 years of age, and it

is possible that this would be the optimal context for ascertaining these kinds of social cognitive processes (e.g. Target et al.,1998; Humfress et al.,2002). Inevitably, however, in the absence of established measures or methods, clinicians will be faced with having to oversee their own experimentation on how best to elicit the child’s ability to link thoughts, feelings and behaviour.

Recommendation for assessing the child’s context is more obvious. Detailed assessment of the child’s family and family relationships is routinely conducted, and its importance is supported by research findings. In addition to assessing symptomatology in the parents, which may both alter and complicate treat-ment, some assessment of the quality of parent–child relationship is indicated.

Fortunately, there are specific guidelines on the dimensions of kinds of parent–

child relationship quality that may be of particular interest. Findings suggesting how the family enhances the child’s avoidance and so maintains and accentuates the child’s symptoms are noteworthy (Barrett et al.,1996; Dadds and Barrett, 1996; Hudson and Rapee,2001); there are, in addition, a number of other dimen-sions of the parent–child relationship that predominate research and are worth incorporating in a clinic assessment of the parent–child relationship, including warmth/support, conflict and monitoring/control and psychological autonomy (see O’Connor,2002).

However speculative the specific recommendations for assessment might be, the recommendation from research for treatment are even less clear. At this point, perhaps the main point worth emphasizing is that experiences in the clinical setting have an illustrious history for generating hypotheses and spurring sys-tematic clinical as well as basic research. Detailed case reports and case audit consideration of the origins of successes and failures in cases would be a helpful start in that direction.

3.6 Conclusions

In conclusion, we offer several summary statements. First, there is, to date, a poor fit between ‘basic’ developmental research into social cognitive processes and clinical/applied research on CBT with children. Furthermore, these lines of investigation rely on largely distinct models and paradigms. Secondly, per-haps as a consequence of the previous point, there is very limited empirical evidence for a developmental model underlying CBT with children. According to published reports, to the extent that the child’s development has been suc-cessfully integrated within a treatment approach, it has been in terms of the context in which CBT is delivered (namely, as part of a family model or not) rather than in terms of how CBT itself may be modified. There are surprisingly

few guidelines concerning what modifications need to be made for younger versus older children (though see Chapter 8) or what assessments should be carried out to determine the appropriateness of such modifications. Thirdly, a thesis underlying this chapter is that a developmental approach to assessment and intervention/prevention would help elucidate the mechanisms of change in CBT with children and identify the predictors of good versus poor response. It remains for future clinical research to test the hypothesis that a developmental model of CBT improves treatment success.

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4

Psychological therapies: a family