Cognitive-BehaviorTherapy for ChildrenTreating Complex andRefractory Cases

DEAN McKAY, PhD, ABPP

ERIC A. STORCH, PhD

Editors

New York

Dean McKay, PhD, ABPP, is Associate Professor, Department of Psychology,Fordham University. He currently serves on the editorial boards of BehaviourResearch and Therapy, Journal of Clinical Psychology, and Journal of AnxietyDisorders, and is Associate Editor of Journal of Cognitive Psychotherapy.He has published over 120 journal articles and book chapters, is editor orco-editor of 8 published or forthcoming books, and has given over 150conference presentations. Dr. McKay has been a member of the ObsessiveCompulsive Cognitions Working Group since 1995. He is Board Certifiedin Behavioral and Clinical Psychology by the American Board of ProfessionalPsychology (ABPP), is a Fellow of the American Board of Behavioral Psychol-ogy and the Academy of Clinical Psychology as well as a Clinical Fellow ofthe Behavior Research and Therapy Society. His research has focused pri-marily on obsessive-compulsive disorder (OCD), body dysmorphic disorder,and health anxiety and their link to OCD and the role of disgust in psychopa-thology. His research has also focused on mechanisms of information-pro-cessing bias for anxiety states. Dr. McKay is also director and founder ofthe Institute for Cognitive Behavior Therapy and Research, a private treat-ment and research center in Westchester County, New York. He resides inPort Washington, New York, with his wife, Dawn, and daughter, Rebecca.

Eric A. Storch, PhD, earned his BA in Psychology from Binghamton Universityin 1997, followed by his MS, MPhil, and PhD degrees in Child-ClinicalPsychology from Teachers College, Columbia University. At the Universityof South Florida, he is currently an Associate Professor of Clinical Psychologyin the Department of Pediatrics and holds joint appointments in the Depart-ments of Psychiatry and Psychology. Dr. Storch is a licensed clinical psychol-ogist and serves as the Director of the University of South Florida ObsessiveCompulsive Disorder Program.

Dr. Storch specializes in the cognitive behavioral treatment of adult andchildhood obsessive-compulsive disorder (OCD), as well as other obsessive-compulsive spectrum disorders (e.g., trichotillomania, tic disorders, bodydysmorphic disorder, skin picking) and anxiety disorders. He is highly re-garded for the psychological treatment of OCD, particularly with regard totreatment-refractory cases. He also has a special interest in the dissemina-tion of effective psychological treatment approaches for OCD and tics aswell as in the development and validation of OCD assessment measures.Dr. Storch has published over 150 peer-reviewed articles. He is the leadeditor on a text entitled Handbook of Child and Adolescent Obsessive-Compulsive Disorder. Dr. Storch has received grant funding from the Na-tional Institute of Mental Health, Obsessive Compulsive Foundation, Na-tional Alliance for Research on Schizophrenia and Depression (NARSAD),Foundation for Prader-Willi Research, and numerous other foundations forhis research on OCD and related topics. He resides in Tampa, Florida, withhis wife, Jill, and their daughter, Maya.

Copyright © 2009 Springer Publishing Company, LLC

All rights reserved.

No part of this publication may be reproduced, stored in a retrieval system, ortransmitted in any form or by any means, electronic, mechanical, photocopying,recording, or otherwise, without the prior permission of Springer PublishingCompany, LLC, or authorization through payment of the appropriate fees tothe Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA01923, 978-750-8400, fax 978-646-8600, info@copyright.com or on the Webat www.copyright.com.

Springer Publishing Company, LLC11 West 42nd StreetNew York, NY 10036www.springerpub.com

Acquisitions Editor: Sheri W. SussmanProduction Editor: Pamela LankasCover design: Mimi FlowComposition: International Graphic Services

Ebook ISBN: 978-0-8261-1687-1

09 10 11 12 / 5 4 3 2 1

Printed in the United States of America by Hamilton Printing.

The author and the publisher of this Work have made every effort to usesources believed to be reliable to provide information that is accurate andcompatible with the standards generally accepted at the time of publication.The author and publisher shall not be liable for any special, consequential, orexemplary damages resulting, in whole or in part, from the readers’ use of, orreliance on, the information contained in this book. The publisher has noresponsibility for the persistence or accuracy of URLs for external or third-party Internet Web sites referred to in this publication and does not guaranteethat any content on such Web sites is, or will remain, accurate or appropriate.

Library of Congress Cataloging-in-Publication Data

Cognitive-behavior therapy for children : treating complex and refractorycases / Dean McKay, Eric A. Storch, editors.

p. ; cm.Includes bibliographical references and index.ISBN 978-0-8261-1686-4 (alk. paper)1. Cognitive therapy for children. 2. Cognitive therapy for teenagers.

3. Child psychotherapy. I. McKay, Dean, 1966. II. Storch, Eric A.[DNLM: 1. Cognitive Therapy—methods. 2. Adolescent. 3. Child. 4. Mental

Disorders—therapy. WS 350.6 C67625 2009]RJ505.C63C646 2009618.92'891425—dc22

2009017312

This book is dedicated to my family, Dawn and Rebecca, for their supportand encouragement and for being such fun travel partners, both on vacationand in life. And for the children whom I have worked with, for creatinga sense of importance in determining effective means of alleviating distress.

—Dean McKay

With much love this book is dedicated to my mother and father, whoinstilled in me both the joy of learning and the importance of helpingothers. And to my daughter, Maya—thank you for being the perfect reasonto come home from work early.

—Eric Storch

Contents

Contributors xvForeword by Wendy K. Silverman xix

PART I: GENERAL ISSUES IN REFRACTORY CASES 1

1 The Challenge of Difficult Cases 3Dean McKay and Eric A. Storch

Empirically Supported Treatments VersusEmpirically Supported Practice 4

Scope of This Volume 5

2 Adjustments in Treatment for Limited or NonrespondingCases in Contemporary Cognitive-Behavioral Therapy WithYouth 9Alyssa M. Marder and Bruce F. Chorpita

Step 1: Assessment of Symptoms and Reflection on TreatmentCourse 11

Step 2: Evaluation of Youth and Family Engagement 15Step 3: Evaluation of Treatment Integrity 24Step 4: Evaluation of Case Formulation 35Step 5: Interference—“The Real World” 38Conclusions 38

3 Adjustments in Treatment for Limited or NonrespondingAdolescents in Contemporary CBT 47Tara Peris and John Piacentini

Defining Treatment Response 48The Scope of the Problem: Examining Rates of Nonresponse 50Adolescents as Nonresponders 53Predictors of Nonresponse in Adolescents 57

vii

viii Contents

Family-Level Predictors of Treatment Outcome 60Therapeutic Process and Treatment Response 61Strategies for Intervening With Treatment-Resistant Mental

Illness 63Assessing the Treatment Trial 63Summary 68

PART II: INTERNALIZING DISORDERS 79

4 Obsessive-Compulsive Disorder in Children and Adolescents:Treating Difficult Cases 81Dean McKay, Eric A. Storch, Brett Nelson, Miguel Morales,and Melanie W. Moretz

Etiology 82Treatment-Interfering Factors 93Case Presentation 98Summary and Future Directions 105

5 Separation Anxiety Disorder 115Cydney J. Van Dyke, Jennifer Regan, and Anne Marie Albano

Effective Treatments 120Factors Associated With Poor Response to CBT 125Case Presentation 128Conclusions and Future Directions 135

6 Cognitive-Behavioral Therapy for Refractory SelectiveMutism 141Sharon C. Sung and Heather L. Smith

Etiology, Phenomenology, and Prevalence Rates 143Age of Onset, Course, and Outcomes 144Treatment for Selective Mutism 145Behavioral Treatments 146Cognitive-Behavioral Treatments 147Treatment Challenges 148Pretreatment Considerations 151Case Presentation 152Diagnostic Profile 154

Contents ix

Pretreatment Goals and Functional Assessment 154Cognitive-Behavioral Formulation and Treatment 155Psychoeducation 156Cognitive-Behavioral Skills Training and Parent/Teacher

Coaching 157Systematic Desensitization With Relaxation Training 157Cognitive Strategies 158Shaping and Contingency Management 158Stimulus Fading and Graded Exposure 160End-of-Academic-Year Case Summary 162Relapse-Prevention Planning 162Conclusions and Future Directions 164

7 Specific Phobias 171Thomas H. Ollendick, Thompson E. Davis III, and Cristian Sirbu

Phenomenology 172Epidemiology and Etiology 173Effective Treatments for Specific Phobia in Children and

Adolescents 174Evidence-Based Treatments 175Factors That Lead to Poor Treatment Response 180Case Presentation 185Assessment 186Case Conceptualization 189Treatment 190Summary 195

8 Children’s Refractory Posttraumatic Stress Disorder:An Ecological, Evidence-Based Perspective 201Elissa J. Brown and Carole L. Campbell

Posttraumatic Stress Disorder in Youth 201Theoretical Argument for and Description of Trauma-Specific

Cognitive-Behavioral Therapy 202Efficacy of Trauma-Specific Cognitive-Behavioral Therapy 205Factors Related to Treatment Outcome 208Case Presentation 212Conclusions and Future Directions 223

x Contents

9 Better But Not Well: Strategies for Difficult-to-TreatYouth Depression 231John F. Curry and Sara J. Becker

Effective Treatments for Youth Depression 233Assessment of Treatment Response in Clinical Research 239Assessment and Treatment of Depression in Clinical Practice 245Case Presentation 247Conclusions 253

10 Cognitive-Behavior Therapy for Eating Disorders in Childhoodand Adolescence 259Sarah Fischer, Angela Celio Doyle, and Daniel le Grange

Symptoms 260Age of Onset and Prevalence in Adolescents 262Etiology and Cognitive-Behavioral Models of the Development of

Eating Disorders 264Adaptation of CBT for Adolescents With Eating Disorders:

Adolescent Development and the Role of the Family 265What Is Known About CBT for Anorexia Nervosa? 268Case Presentation—Treatment of Anorexia with CBT 270Cognitive-Behavioral Treatment of Bulimia Nervosa 273Case Presentation—Treatment of Adolescent BN With CBT 277Summary 284

11 Assessment and Treatment of Child and Adolescent SleepDisorders 293Connie J. Schnoes and Thomas M. Reimers

Pediatric Sleep Disorders 294Assessment 300Treatment 304Case Presentation 316Future Directions 319

PART III: EXTERNALIZING DISORDERS 325

12 Adjunctive Cognitive-Behavior Therapy for PediatricBipolar Disorder 327Jen Kogos Youngstrom, Norah Feeny, Eric A. Youngstrom, Tymesha Buckner,and Carla Kmett Danielson

Contents xi

Limited Empirically Supported Treatments Available for PediatricBipolar Disorder 328

Factors Associated With Poor Treatment Response 332Cognitive-Behavior Therapy Treatment Manual for Bipolar

Youth 333Phase I: Psychoeducation and Goal Setting 337Phase II: Basic Skill Acquisition 338Phase III: Advanced Skills 341Phase IV: Combining Skills to Address Common Problems—

Optional Modules 344Phase V: Wrap-Up, Relapse Prevention, and Maintenance 347Case Presentation 347Future Directions 356

13 Oppositional Defiant and Conduct Disorders 367Clint E. Field

Primary Symptoms and Diagnostic Criteria 368Oppositional Defiant Disorder 369Conduct Disorder 369Characteristics of Disruptive Behavior Problems 370Risk and Causal Factors 371Effective Treatment for Conduct Problems 373Factors Associated With Poor Treatment Response 375Case Presentation 378Conclusions and Future Directions 385

14 Treatment of Refractory Cases of Attention-Deficit/Hyperactivity Disorder in Children 393Erin L. Girio, Lauren Richerson, and Julie Sarno Owens

ADHD: Diagnosis, Prevalence, and Associated Impairments 394Empirically Supported Treatments for ADHD 396Cognitive-Behavioral Treatments for ADHD 400Predictors of Poor Treatment Response 400Case Presentation 406Conclusions 413

15 The Challenges of Working With Young People DiagnosedWith Asperger Syndrome 421Kate Sofronoff and Renae Beaumont

xii Contents

Managing Anxiety 423Program Outline 424Barriers to Treatment 425Improving Children’s Social Functioning 429Case Presentation 438Conclusions and Future Directions 440

16 Nocturnal Enuresis and Encopresis: Empirically SupportedApproaches for Refractory Cases 445Mary L. Keeley, Paulo Graziano, and Gary R. Geffken

Introduction to Enuresis 445Treatment of Enuresis 446Refractory Responses to Treatment of Pediatric Nocturnal

Enuresis With the Moisture Alarm 450Introduction to Encopresis 457Refractory Responses to the Treatment of Pediatric Encopresis 460Case Presentation 464Conclusions and Future Directions 467

17 Cognitive-Behavior Therapy for Children and Adolescents WithDifficult-to-Treat Substance-Use Disorders 475Lisa J. Merlo and Amanda M. Stone

Detection of Substance-Use Disorders in Pediatric Patients 477Prevalence of Substance-Use Disorders Among Children

and Adolescents 478Factors Associated With Development of Substance-Use

Disorders 479Course of the Substance-Use Disorders 481Cognitive-Behavioral Therapy for Children and Adolescents With

Substance-Use Disorders 483Factors Associated With Poor Treatment Response 485Adjunctive Treatments to Improve Treatment Retention and

Outcome 487CBT for Difficult-to-Treat Cases 492Case Presentation 493Conclusions and Future Directions 496

18 Treatment of Disorders Related to Feeding in PediatricPopulations 503Wendy N. Gray and David M. Janicke

Contents xiii

Pediatric Obesity 503Pediatric Feeding Disorders 513Case Presentations 522Conclusions and Future Directions 526

19 Tourette’s Syndrome 533Christine A. Conelea, Michael R. Walther, and Douglas W. Woods

Prevalence and Demographics 533Age of Onset and Course 534Functional Impairment 534Etiology 535Comorbidity 537Assessment and Differential Diagnosis 537Treatment 540Factors Related to Poor Response to HRT 543Case Presentation 548Conclusions and Future Directions 551

20 Charting a Course for the Future:Empirically Supported Procedures, TranslationalApproaches, and Models for Complex Cases 559Eric A. Storch and Dean McKay

Tailoring Treatment to the Individual 560Translational Research 561Dissemination 562Conclusion 563

Index 567

Contributors

Anne Marie Albano, PhD, Department of Psychiatry, Columbia Univer-sity College of Physicians and Surgeons, New York, New York

Renae Beaumont, BSc (Hons), PhD, School of Psychology, Universityof Queensland, Brisbane, Australia

Sara J. Becker, MA, Department of Psychology and Neuroscience, DukeUniversity, Durham, North Carolina

Elissa J. Brown, PhD, Department of Psychology, St. John’s University,Queens, New York

Tymesha Buckner, MA, Applewood Centers, Elyria, Ohio

Carole L. Campbell, PhD, Department of Psychiatry, Children’s Hospi-tal of the King’s Daughters, Norfolk, Virginia

Bruce F. Chorpita, PhD, Department of Psychology, University of Cali-fornia–Los Angeles, Los Angeles, California

Christine A. Conelea, MS, Department of Psychology, University ofWisconsin–Milwaukee, Milwaukee, Wisconsin

John F. Curry, PhD, Professor and Director of Clinical Psychology,Department of Psychology and Neuroscience, Duke University, Dur-ham, North Carolina

Carla Kmett Danielson, PhD, Assistant Professor, Department of Psy-chiatry, Medical University of South Carolina, Charleston, SouthCarolina

xv

xvi Contributors

Thompson E. Davis III, PhD, Department of Psychology, LouisianaState University, Baton Rouge, Louisiana

Angela Celio Doyle, PhD, Department of Psychiatry, University ofChicago, Chicago, Illinois

Norah Feeny, PhD, Associate Professor, Department of Psychiatry, CaseWestern Reserve University, Cleveland, Ohio

Clint E. Field, PhD, Director, Psychology Community Clinic, Depart-ment of Psychology, Utah State University, Logan, Utah

Sarah Fischer, PhD, Assistant Professor, Department of Psychology,University of Georgia, Athens, Georgia

Gary R. Geffken, PhD, Department of Psychiatry, University of Florida,Gainesville, Florida

Erin L. Girio, MA, Department of Psychology, Ohio University, Ath-ens, Ohio

Daniel le Grange, PhD, Department of Psychiatry, University of Chi-cago, Chicago, Illinois

Paulo Graziano, MA, Department of Clinical and Health Psychology,University of Florida Health Center and Department of Psychology,University of North Carolina at Greensboro, Greensboro, NorthCarolina

Wendy N. Gray, MS, Department of Clinical and Health Psychology,University of South Florida, Gainesville, Florida

David M. Janicke, PhD, Department of Clinical and Health Psychology,University of South Florida, Gainesville, Florida

Mary L. Keeley, MS, Department of Clinical and Health Psychology,University of Florida Health Center and Department of Psychiatry andBehavioral Sciences, Emory University, Atlanta, Georgia

Contributors xvii

Alyssa M. Marder, PhD, Department of Psychology, University of Cali-fornia–Los Angeles, Los Angeles, California

Lisa J. Merlo, PhD, Assistant Professor, Department of Psychiatry, Uni-versity of Florida, Gainesville, Florida

Miguel Morales, MD, Child Psychiatrist, Departments of Pediatrics andPsychiatry, University of South Florida, Gainesville, Florida

Melanie W. Moretz, PhD, Department of Psychology, Fordham Univer-sity, Bronx, New York

Brett Nelson, MD, Departments of Pediatrics and Psychiatry, Universityof South Florida, Gainesville, Florida

Thomas H. Ollendick, PhD, Department of Psychology, Child StudyCenter, Virginia Polytechnic Institute and State University, Blacks-burg, Virginia

Julie Sarno Owens, PhD, Department of Psychology, Ohio University,Athens, Ohio

Tara Peris, PhD, Department of Psychiatry, University of California–LosAngeles School of Medicine, Los Angeles, California

John Piacentini, PhD, Department of Psychiatry, University of Califor-nia–Los Angeles School of Medicine, Los Angeles, California

Jennifer Regan, BA, Department of Psychiatry, Columbia UniversityCollege of Physicians and Surgeons, New York, New York

Thomas M. Reimers, PhD, Clinic Director, Boys Town Pediatric andFamily Services Clinic, Clinical Associate Professor, Creighton Univer-sity School of Medicine, Omaha, Nebraska

Lauren Richerson, PhD, Department of Psychology, Ohio University,Athens, Ohio

Connie J. Schnoes, PhD, Boys Town Pediatric and Family ServicesClinic, Boys Town, Nebraska

xviii Contributors

Cristian Sirbu, MD, PhD, Charleston Area Medical Center Health Edu-cation and Research Institute and West Virginia University School ofMedicine–Charleston Division, Charleston, South Carolina

Heather L. Smith, PhD, Department of Psychiatry, Montefiore Hospitaland Albert Einstein School of Medicine, Bronx, New York

Kate Sofronoff, PhD, School of Psychology, University of Queensland,Brisbane, Australia

Amanda M. Stone, MA, Department of Psychiatry, University of Florida,Gainesville, Florida

Sharon C. Sung, PhD, Department of Psychiatry, Montefiore Hospitaland Albert Einstein School of Medicine, Bronx, New York

Cydney J. Van Dyke, MA, Department of Psychology, Fordham Univer-sity, Bronx, New York

Michael R. Walther, BS, Department of Psychology, University of Wis-consin-Milwaukee, Milwaukee, Wisconsin

Douglas W. Woods, PhD, Department of Psychology, University ofWisconsin-Milwaukee, Milwaukee, Wisconsin

Eric A. Youngstrom, PhD, Department of Psychology, University ofNorth Carolina–Chapel Hill, Chapel Hill, North Carolina

Jen Kogos Youngstrom, PhD, Department of Psychology, University ofNorth Carolina–Chapel Hill, Chapel Hill, North Carolina, andApplewood Centers, Elyria, Ohio

Foreword

Readers of Cognitive-Behavior Therapy for Children: Treating Complexand Refractory Cases are likely drawn to this book to learn more abouthow to alleviate most effectively the distress of children and adolescentswho suffer from psychiatric disorders. The development and evaluationof psychological treatments has yielded an array of interventions withscientific documentation to help affected youth. Mental health profes-sionals, as a consequence, have at their disposal many available methodsby which to reduce child and adolescent disorders. Most of these meth-ods rely on cognitive-behavioral treatment procedures. Although theprobability is high that other treatments currently in use in the field,as well as treatments under development or interventions yet to bedeveloped, are also effective, one cannot deny that cognitive-behavioraltherapy (CBT) has advanced most significantly over the past decades.

In this context, the current volume is significant because it addresseshead-on an issue that has been generally neglected in the literature.Namely, despite the availability of effective CBTs to address key childand adolescent disorders, including those that are covered in this book(e.g., depression, separation anxiety disorder), substantial proportionsof youth treated with evidence-based CBT protocols fail to show symp-tomatic improvement at posttreatment evaluations. This book doesnot sweep this fact under the rug, neither does it transmit a sense ofhopelessness and helplessness to a subset of child and adolescent clients.Instead, the editors have brought together leading experts to synthesizeand analyze a body of research on treatment outcome predictors andbarriers of treatment for the different disorders. Chapter authors co-gently describe barriers to treatment implementation and recommendsystematic adjustments to help improve the outcomes of formerly refrac-tory child and adolescent clients.

The current volume is significant on another level. This book high-lights the fact that the sharp distinctions often drawn in the literature

xix

xx Foreword

between efficacy and effectiveness can be misleading. “Efficacy” refersto whether a particular CBT has been found to “work” by means ofexperimental procedures. “Effectiveness” refers to whether a particularCBT has been found to “work” in settings and under conditions inwhich the treatment will typically be delivered, such as in privatepractice and community mental health clinics. The chapters containedherein highlight the notion that the child and adolescent psychologicaltreatment research literature is better characterized as falling along acontinuum with respect to efficacy and effectiveness. Many so-calledefficacy studies are high in external validity and many so-called effective-ness studies use rigorous internal validity or controls. It is this contin-uum between efficacy and effectiveness that made it possible for thechapters’ authors to blend lessons learned from both areas to formulaterecommendations about the handling of complex and refractory cases.These recommendations are not only empirically informed but are alsorichly illustrated through case examples that showcase the authors’clinical acumen and skills.

Cognitive-Behavior Therapy for Children: Treating Complex and Re-fractory Cases thus represents an important effort in narrowing the gapbetween research and practice. The reluctance of many clinicians toadopt evidence-based treatments in their practices often occurs becausethey have found that these treatments may help some of their clients,but, for other clients, the treatments did not help or helped only partially.Families dropped out, children could not become engaged, debilitatingcomorbid symptoms interfered with the CBT procedures, and otherextant factors were operating. The chapters in hand delineate thesefactors for each of the disorders covered. Clinicians can turn to thesechapters when faced with the challenge of treating clients whose mani-festations do not permit application of evidence-based CBT protocolsas described in the literature. Having an understanding of these issuesprovides the clinician in practice with the flexibility to be adaptable tovariations in problem, context, or condition.

The chapters also provide a valuable guide that researchers canturn to in their efforts to expand the current evidence base for child andadolescent psychological treatments. The chapters’ coverage of whichsubgroups of child and adolescent patients show optimal response tocurrent intervention strategies, and which subgroups do not, is essentialto “get at” moderators of treatment outcome. The chapters’ coverage

Foreword xxi

of how treatments need to be adjusted for certain cases is also essentialto get at mediators of treatment outcome.

Consequently, the chapters suggest avenues for future study designsthat might include comprehensive and systematic assessments to mea-sure hypothesized moderating and mediating variables. Such designsmight also include the assessment of why child and adolescent clientsdo not adhere to CBT protocols. Such designs, which move beyond the“basic” pre–post randomized clinical trial design, will ultimately lead tosignificant theoretical advances about child and adolescent psychosocialtreatments and, concomitantly, lead to more effective and better treat-ments for these debilitating child and adolescent disorders.

The result, I hope, of Cognitive-Behavior Therapy for Children: Treat-ing Complex and Refractory Cases is that it will help to optimize themental health interventions that children and adolescents deserve toreceive—treatments that have, at their core, the theory and methodsof CBT. It is also my hope that this important volume will reduce thebarriers that currently exist in the implementation of evidence-basedCBTs in clinical and community practice settings.

Wendy K. Silverman, PhD, ABPPProfessor of PsychologyFlorida International UniversityMiami, Florida

PARTI

General Issuesin Refractory Cases

1 The Challenge of Difficult CasesDEAN McKAY AND ERIC A. STORCH

At the present time, there are empirically supported treatments for mostof the major psychiatric diagnoses that may be identified in childrenand adolescents. The advent of these empirically supported approacheshas been critical in providing a heuristic for developing treatment plansfor affected youth. No client neatly fits into the ideal template for anyempirically supported treatment program, however. There are innumer-able client-specific factors that may alter the nature and outcome ofeven the most carefully conducted therapy program.

A sign of maturity for any treatment research program is the abilityto move beyond interventions for specific diagnoses and address, sys-tematically, prognostic limitations that might interfere with standarddelivery of care. Cognitive-behavioral therapy (CBT) has advanced sig-nificantly over the past quarter century. When refractory cases werefirst systematically discussed for adult clients, there were two importantdistinctions that occurred. First, many clinicians were resigned to thenotion that nonresponders were “treatment failures” often directly orindirectly conveying a sense of hopelessness to a subset of clients (Foa &Emmelkamp, 1983). Second, 25 years ago there was a limited body ofliterature on empirically supported treatment and virtually no dataavailable on outcome predictors. Instead, CBT-oriented clinicians were

3

4 Cognitive-Behavior Therapy for Children

refining individual techniques and only beginning to see CBT’s wide-spread applicability to diagnoses (Franks & Wilson, 1973).

As is so often the case, many of the empirically supported approachesfor major psychiatric diagnoses were developed with adults in mind.To this end, the ability to describe barriers to treatment implementationand the inclusion of empirically supported modification to these thera-pies has progressed faster for adults and has recently been summarized(McKay, Abramowitz, & Taylor, in press). Nonetheless, there appearsa widespread reluctance to consider refractory cases, perhaps becauseof the inherent difficulty associated with the term. Fortunately, as moreresearchers endeavor to address poor prognostic signs, the ability toaddress these problems will help move formerly refractory clients intoa different category, perhaps merely referenced by the diagnosis withspecial modifiers.

Whereas there are now two texts that deal directly with refractorycases in adult disorders (Foa & Emmelkamp, 1983; McKay et al., inpress), this book is the first to cover this topic in children and adoles-cents. The importance of addressing such cases may serve the purpose ofbridging the gap between laboratory and controlled treatment outcomeresults and applicability in the clinic. For example, Weisz and colleagues(Weisz, Donenberg, Han, & Weiss, 1995) found that outcomes withchildren and adolescents were generally poorer for specific diagnoseswhen treated in community clinic settings when compared with proto-cols for empirically supported treatments. On the one hand, this maysimply reflect the variations and unreliability of uncontrolled treatmentimplementation. On the other hand, it also likely reflects the varietyof known complicating factors that often lead to exclusion from clinicaltrials, particularly in the early stages of treatment development.

EMPIRICALLY SUPPORTED TREATMENTS VERSUSEMPIRICALLY SUPPORTED PRACTICE

In some respects, the movement to identify factors that may interferewith standard delivery of empirically supported treatment packages isa movement back to the early days of behavior therapy. At that time,there was limited reliance on diagnosis, and instead a focus on functionalanalyses of behavior that allowed for identification of theory-drivenempirically supported techniques. The approach of empirically sup-ported practice (McKay & Tryon, 2002) or, in a nod to classification,

Chapter 1 Difficult Cases 5

the transdiagnostic approach (Harvey, Watkins, Mansell, & Shafran,2004), is consistent with the broader approach to training cliniciansbased on principles of psychological clinical science (for a historicalperspective, see Bootzin, 2007). A comparison that summarizes thisdistinction is in order. Engineers building a bridge do not rely on amanual for bridge building, but are daunted by limitations such asvariations in river width or tidal changes that deviate from the originallyempirically supported approach to building a bridge. Instead, there area set of theoretically derived principles that guide bridge building,with limitations coming also from that same theory (i.e., water depthcombined with width of expanse). Psychological science may be enter-ing a similar phase of treatment development.

With respect to childhood disorders, we are perhaps better posi-tioned to use previously empirical support than for adult disorders.Many empirically supported treatments for children are age-downwardextensions of the same protocol for adults. A notable example is thetreatment of childhood obsessive-compulsive disorder (OCD). The earlyempirically supported treatment involves exposure with response pre-vention. This approach, even with modifications drawn from cognitivetherapy, remains the key therapeutic element in treatment for adultswith the disorder (Abramowitz, Taylor, & McKay, 2005). However, inthe case of children with OCD, it is not necessarily the case that therewill be good insight into the disorder. In adults, poor insight is also apoor prognostic indicator for the disorder (McKay & McKiernan, 2005).In such instances, exposure-based treatments are not necessarily ad-vised. This would suggest a modified approach, or one that does notrely at all on previously successful approaches used with adults. In thecase of diagnoses first identified in childhood (e.g., attention-deficit/hyperactivity disorder [ADHD]; separation anxiety disorder), treat-ments may be developed specifically with children in mind, an unusualscenario in psychological interventions. In fact, it is in this arena thatthere may be age-upward extensions to adult presentations of similarproblems. Such is the case with ADHD, where at least in the case ofpsychopharmacological management, there are now numerous trials ofstimulant medication for attention problems in adults (Davidson, 2008).

SCOPE OF THIS VOLUME

This book has been developed with both researchers and clinicians inmind. We considered researchers as we sought to identify prognostic

6 Cognitive-Behavior Therapy for Children

signs that would be the source of future research into developing andrefining treatment for a wide range of childhood disorders. We boreclinicians in mind as they face the challenge of treating clients whopresent with what immediately may fit neatly into a diagnostic category,but whose specific manifestation of the condition does not permit appli-cation of the standard protocols as described in the published literature.

The book is organized into three major sections. The first providesan overview of general considerations that may lead to barriers intreatment for children and adolescents. As noted earlier, many empiri-cally supported approaches are age-downward extensions of previouslyvalidated approaches for adults. However, childhood and adolescenceare complex developmental periods. When psychopathology intrudeson youth, there are specific considerations in developing treatments,and special barriers to implementation that must be addressed. Shouldone fail to contend with these special considerations, treatment mayfail before one even reaches a prognostic barrier that is unique to thediagnosis in question.

The second section deals with issues involving internalizing disor-ders, or those related to inner emotional disturbance. Oftentimes, thesechildren present with problems that are a source of disturbance forparents and child alike, but do not necessarily rise to the attention ofschool personnel. Many of the disorders in this section conform to theage-downward extension model of treatment development. The finalsection addresses externalizing disorders. Most of these conditions areones initially identified in childhood. Clinicians treating these disordersmust often devote significant energy working with other personnel (i.e.,school personnel, other providers) as well as parents, and perhaps spendmore time with these individuals than with the identified child client.In both sections on internalizing and externalizing disorders, case illus-trations are provided detailing ways in which treatment was modifiedfrom the original approach to address complicating factors.

It is our hope that this text will inform researchers and cliniciansalike as they provide services to children and adolescents with a widerange of psychopathology. In light of the advances in the delivery ofCBT, we feel that this is a timely occasion to consider the wide rangeof psychotherapy modifications available to address factors that maynegatively impact outcome.

Chapter 1 Difficult Cases 7

REFERENCES

Abramowitz, J. S., Taylor, S., & McKay, D. (2005). Potentials and limitations of cognitivetreatments for obsessive-compulsive disorder. Cognitive Behaviour Therapy, 34,140–147.

Bootzin, R. R. (2007). Psychological clinical science: Why and how we got to wherewe are. In T. A. Treat, R. R. Bootzin, & T. B. Baker (Eds.), Psychological clinicalscience: Papers in honor of Richard M. McFall (pp. 1–28). New York: Taylor & Francis.

Davidson, M. (2008). ADHD in adults: A review of the literature. Journal of AttentionDisorders, 11, 628–641.

Foa, E. B., & Emmelkamp, P. M. G. (1983). Failures in behavior therapy. New York:Wiley.

Franks, C. M., & Wilson, G. T. (1973). Annual review of behavior therapy. Oxford, UK:Brunner/Mazel.

Harvey, A., Watkins, E., Mansell, W., & Shafran, R. (2004). Cognitive behaviouralprocesses across psychological disorders: A transdiagnostic approach to research andtreatment. Oxford, UK: Oxford University Press.

McKay, D., Abramowitz, J.S., & Taylor, S. (in press). Cognitive behavior therapy forrefractory cases: Turning failure into success. Washington, DC: American Psychologi-cal Association.

McKay, D., & McKiernan, K. (2005). Information processing and cognitive behaviortherapy for obsessive-compulsive disorder: Comorbidity of delusions, overvaluedideas, and schizophrenia. Cognitive and Behavioral Practice, 12, 390–394.

McKay, D., & Tryon, W.W. (2002). Behavior therapy: Theoretical bases. In W. Sledge &M. Hersen (Eds.), Encyclopedia of psychotherapy (Vol. 1, pp. 277–291). San Diego,CA: Academic Press.

Weisz, J. R., Donenberg, G. R., Han, S. S., & Weiss, B. (1995). Bridging the gap betweenlaboratory and clinic in child and adolescent psychotherapy. Journal of Consultingand Clinical Psychology, 63, 688–701.