Chapter 12 Psychotherapy with Children
What defines the field of child psychotherapy? For anyone over a certain age, a mention of child psychotherapy conjures up an image of play therapy and a dynamic, drive-theory orientation to a child’s behavioral problems. A history of child therapy would most likely begin in the 1930s and early 1940s, when the ideas of Anna Freud and Melanie Klein predominated (West & Evans, 1992). Although psychodynamic and play-therapy techniques have continued to be refined and have broadened to include expressive therapies (Chethik, 2000; Schaefer, 2003), the dominance of the psychodynamic school has subsided (Ritvo et al., 1999). Child psychodynamic practice has drawn consistent criticism for the lack of empirical data on its effectiveness (Barnett et al., 1991; Levitt, 1957; Marans, 1989). Although acknowledged as containing key concepts of personality, its “Achilles heal” continues to be the failure to compile a convincing body of outcome or effectiveness data (Remschmidt & Quashner, 2001).
Hibbs (2001) believes that a data-based, scientific approach to solving specific behavioral problems contributed to the ascendancy of child behavioral treatments in the 1960s and 1970s. Through the 1990s, the trend continued toward time-limited interventions aimed at producing symptom-specific outcomes (Bloom, 2002), and increasingly, child psychotherapy was defined by techniques and their accompanying school of therapy (e.g., interpersonal, systemic, cognitive-behavioral, family) (Roth & Fonagy, 1996). In their last policy statement on child psychotherapy, the American Academy of Child and Adolescent Psychiatry (AACAP) endorsed the notion of psychotherapy as treatments residing in these established therapy schools (American Academy of Child and Adolescent Psychiatry [AACAP], 1998b).
At the same time, an important shift was occurring in how therapies were organized. Through the 1990s, child psychosocial interventions were increasingly classified by the major disorders treated in the United States: anxiety related, depression related, attention problem, and conduct disorders (Weisz et al., 2004). Organizing intervention by diagnosis was furthered by the work of the members of the American Psychological Association, Division 12, Society of Clinical Psychology, who created a way to rate the evidence supporting psychological interventions (American Psychological Association [APA], 1993). In the child field, what followed were extensive treatment reviews for specific childhood disorders, such as anxiety disorder, attention deficit hyperactivity disorder (ADHD), and autism (Burns, 2003). Such an organizational scheme for rating evidence also lent itself to analysis of clinical trial research; it was compatible with another emerging movement, defining evidence-based practices (EBPs). What have emerged from this movement are very specific interventions for particular disorders. The field is moving toward child psychotherapy being defined and organized by EBPs.
Advanced Practice Psychiatric Nurses: Training and Certification
Psychiatric nurses are key participants in the coordination of mental health care for children and bring a particular nursing orientation and expertise to the field. The scope of practice for child psychiatric nurses sets down these particular areas of emphasis; the value of the relationship, a health focus, view of the child in relation to social systems, and the application of science to treatment (i.e., psychological interventions and the neurobiology of illness) (American Nurses Association [ANA], 1985). Preparation for advanced practice psychiatric nurses (APPNs) occurs at the graduate level and includes training in multiple bodies of knowledge (i.e., medical science, neurobiology of psychiatric disorders, health systems, treatment methods, psychopharmacology, and relationship science). APPNs bring this distinct orientation into their work with children by the way they respond and view phenomena.
Advanced practice child and adolescent psychiatric nurses have several certification options. The American Nurses Credentialing Center (ANCC) offers two types of examinations for graduates of psychiatric–mental health (PMH) master’s degree programs. ANCC’s Child and Adolescent Clinical Specialist (CS) examination targets advanced practice nurses who will focus on a CS role, traditionally a combination of case management and therapy. The ANCC Psychiatric Family Nurse Practitioner (NP) examination was designed for PMH Advanced Practice Nurses who will assume a primary mental health care role with children and adolescents. This is considered a broader role because it includes psychopharmacologic management. Many nursing leaders believe that in PMH nursing, there are no real distinctions between the CS and NP roles and that the future will bring a combined role with its own certification examination (Delaney, 2005).
Child Therapy Organized by Evidence-based Practices: Underlying Assumptions
Evidence-Based Practices in the Child Field
Therapies and psychological approaches become EBPs by means of clinical trials in which defined groups of participants receive a standardized treatment. Most often, members of this participant group have similar behaviors or presentations such that they meet select diagnostic criteria. A particular EBP often demonstrates efficacy for a particular diagnoses. The convention of linking EBPs to diagnosis is reinforced by publications such as practitioner reviews (James & Javaloyes, 2001), research summaries of particular disorders (Schachar et al., 2002; Weisz et al., 2004), practice guidelines (Brown et al., 2005), and texts describing specific EBPs in detail (Hibbs & Jensen, 1996; Kazdin & Weisz, 2003).
Based on a review of the literature, it seems there is much to choose from when considering an EBP approach for this population. Although the body of evidence-based child practices does not equal those amassed in the adult field, reviews and analysis of effective treatment modalities indicate the growing strength of the child specialty (American Psychological Association, Division 12, 1993; Compton et al., 2002; Farmer et al., 2002; Hibbs, 2001; Rzepski & Jarasdek, 2005; Weisz et al., 2004) (Box 12-1). With the advent of web-based searches and guidelines for organizing research literature, the hope is clinicians will achieve a comfort level with isolating the best available, most effective approach to a child’s presentation (Ollendick & Davis, 2004). The logical result of this effort is moving the child field toward defining child psychotherapy by EBPs and its accompanying diagnosis (Weisz et al., 2004). However, a therapy system organized by diagnosis and its attendant EBP is not without issue.
Box 12-1 Four Sources of Evidence-Based Practice Guidelines for Child Treatment
Practice guidelines developed by professional groups (AACAP, 1997a, 1997b, 1998a, 1998b; Conners et al., 2001).
Clinical trial results: For disorders without child guidelines, such as posttraumatic stress disorder, therapists may orient themselves with child-specific clinical trial work (Cohen et al., 2005, 2004).
Treatment reviews (James & Javaloyes, 2001; Pavuluri et al., 2005) and initial research on promising psychosocial approaches (Pavuluri et al., 2005).
Pediatric Literature contains practice guidelines for primary care (Brown et al., 2005).
Issues with an Evidence-Based Practice Model
Organizing child interventions by EBPs and diagnoses envisions a future in which the therapist will line up a diagnosis and a suitable evidence-based intervention. This may seem a logical approach; it is difficult to argue against using therapies that are proved effective. However, this convention is not without issue, issues that come to light by examining several of assumptions of an EBP therapy system.
One underlying assumption is that eventually there will be an EBP to match most behaviors of children who present for treatment in the mental health system. Although significant strides have been made in developing a menu of evidence-based treatments for children, the child specialty has not built a body of clinical trial evidence supporting treatment for every diagnostic category. Reviews of articles of child-specific EBPs demonstrate progress in the treatment of adolescent depression and ADHD (Brown et al., 2005; Hamerin & Pachler, 2005), but there is much work to be done, particularly in the areas of posttraumatic stress disorder (PTSD), pediatric bipolar disorder (PBD), and anorexia (Burns, 2003). Moreover, the literature continues to propagate numerous scientifically questionable treatments, especially for disorders such as autism, ADHD, and conduct disorders (Lilienfeld, 2005).
Another assumption of the evolving system is that clinicians will proceed in a linear fashion from assessment to diagnosis to locating the appropriate EBP. However, diagnosis in the child and adolescent fields comes with a host of considerations (Chorpita, 2003). Children’s psychiatric diagnoses are not static; they can change over the years. The current popular taxonomies do not provide for a youth’s presentation that may be a blend of dimensions, each akin to several disorders (Lahey et al., 2004). With children, comorbid disorders are the rule rather than the exception, especially for children diagnosed with depressive spectrum and attention disorders (Cuffe et al., 2005; Hamrin & Pachler, 2005). Promising community-based interventions, such as multisystemic therapy (MST), are not tied to a particular diagnosis (Burns, 2003).
Another assumption is that EBPs primarily designed and tested as child-centered approaches will be what families want or need. Speaking for the voice of parents, Flynn (2005) described families’ issues with EBPs; primarily, there are too few, they are poorly translated into “real world practice,” and they disregard the family’s role in the treatment planning. As Flynn (2005) emphasized, children and adolescents must be treated in the context of their school lives, families, and communities. The outcomes families seek (e.g., improved school performance, competency, enhanced peer relationships) are not necessarily the direct outcomes of applying an EBP.
A therapy model organized around EBPs overlooks the reality that children and adolescents with serious emotional disorders have a variety of interconnected needs. Research demonstrates that youths with serious emotional disorders are likely to have comorbid disorders, be severely impaired, and be experiencing problems in multiple areas of their lives (e.g., school, family) (Pottick et al., 2004). Within the population of youths with serious emotional disorders are cohorts of children with particular needs arising from maltreatment, being in foster care, or involvement in the juvenile justice system (DosReis et al., 2001; Racusin et al., 2005; Thomas et al., 2005). Children with complex needs will require an approach that simultaneously addresses their multiple social needs and issues arising from their serious emotional disorders.
Principles and Guidelines for Child Mental Health Psychotherapy
Efforts to build a system of EBPs and disseminate them in practice should be vigorously continued. However, child psychotherapy should not necessarily be organized around EBPs. As articulated by parents, the first guiding principle of child psychotherapy should be its focus on developing a package of services that contribute to a wide variety of “real-world” outcomes. Guidelines have not been formally written for this type of therapy system, but statewide models exist that integrate EBPs into community services (Burns, 2003). There are several variations within this approach, such as distilling the core elements of EBPs and then putting forth a menu from which the parent and clinician customize a treatment plan (Chorpita et al., 2005). Another model combines evidence-based interventions within the context of usual care at community-based practice settings (Garland et al., 2006). Combining EBPs with coordinated community services that assist patients with recovery or resiliency is also at the heart of the government’s plan for a transformed mental health care system (Substance Abuse and Mental Health Services Administration [SAMHSA], 2005).
A second principle of a 21st century child psychotherapy system is that clinicians operate from an embedded norm of family involvement in treatment decisions. Family involvement begins when treatment is initiated, enlisting the parent’s view of treatment needs and establishing goal congruence (i.e., a consensus about the goals of therapy and the means to accomplish those goals) (Green, 2001). This orientation, sometimes called a family-centered system of care approach (Institute of Medicine [IOM], 2006), should be firmly integrated into all aspects of treatment planning. For psychiatric nurses, the notion of family involvement may be less ingrained than the concept of the one-to-one therapeutic relationship. However, the idea of family involvement has an important history and critical place in treatment, one nurse psychotherapists should understand (Box 12-2).
Box 12-2 Key Events and Principles in Family Centered Care Approach
Children and Adolescent Service System Program (CASSP) established. The overarching goals of CASSP were to coordinate community services for children with serious emotional needs. CASSP principles also emphasized that parents should be empowered, be treated as partners in care, and participate fully in treatment planning (Day & Roberts, 1991).
Systems of Care Approach is defined. These principles moved into a broader systems of care approach to treatment (Stroul & Friedman, 1996) with the creation of agencies and funding that ensured comprehensive community-based services would be available for families of children with serious emotional illness. The emphasis shifted to establishing networks for delivering individualized service plans embedded in comprehensive, culturally competent, coordinated service networks.
A family-centered approach does not necessarily mean that the family is the focus of treatment. Family treatment is appropriate to improve family interactions, for keeping families engaged in services, or to increase their knowledge about mental health (Hoagwood, 2005; Reyno & McGrath, 2006). For some children, an individual approach with a family component may be the appropriate treatment combination (Burns, 2003). Other children require a multisystem approach in which interventions are aimed at the various systems that interact with the child, using nonprofessionals as the agents who intervene with the child (Henggeler et al., 2002). The key is designing therapy that is family centered, evidence based, and comprehensive.
Goals: Use of a Three R Method
How can the nurse psychotherapist conceptualize the process of using a family-centered approach to nest EBPs into community services while remaining consistent with SAMHSA’s vision of a transformed mental health care system? It can be thought of as 3Rs: relationship, resiliency, and regulation. A 3R scheme has been used in various instances as a way to define the core elements therapy (Mahoney, 2004; Moller & Murphy, 1997). The tradition was set by Frank with his classic 3Rs: the relationship, the model or rationale for treatment, and the rituals or “work” of therapy (Frank & Frank, 2004). These common characteristics of therapy have been applied to the child field by Roth and Fonagy (1996) to include the relationship, model, and interpersonal context of treatment. My intent in redefining the essential elements for child psychiatric nurses is an effort to nest nursing’s traditional approach (i.e., relationship-based, health-focus, and systems orientation) within a projection of how nursing may operate in the future (i.e., combining the emerging neuroscience of illness or treatment and a service system with the consumer at center stage). The remainder of the chapter discusses these three core concepts—relationship, resiliency, and regulation—and considers how the APPN can put these therapy elements into action.
Relationship
The therapeutic nurse-patient relationship is at the core of psychiatric nursing practice and provides the key context for all interactions with patients (Beeber, 1995; Ryan & Brooks, 2000). The nurse-patient relationship in the adult literature has been predominately shaped by the Peplau stage framework (O’Brien, 2001). The child psychiatric nursing literature stays within the Peplau tradition but emphasizes developmental aspects that impact the relationship (West & Evans, 1992). Consulting child therapy books yields numerous suggestions about what therapist behaviors promote the child-therapist relationship.
A straightforward approach is to build the relationship on the therapist’s efforts to convey understanding, respect, and a desire to be of help (Reisman & Ribordy, 1993). However, the child-therapist relationship has come to include many more behaviors (Karver et al., 2006). To conduct a search the literature on the topic required, Karver and associates (2006) entered 29 constructs they believed were associated with the child-therapist relationship (e.g., positive regard, attachment, comfort, cooperation, treatment involvement). Although child therapists may universally acknowledge that the relationship is important, distilling the essential qualities is difficult. One tactic for narrowing the definition is to inspect the view that particular relationship qualities tie to therapy outcomes.
This is a popular tactic in the adult literature, in which the idea of the relationship has been broken down into the notion of the alliance and its component elements of empathy, goal congruence, and genuineness (Norcross, 2002). These relationship qualities have been deemed particularly important because of their proven association with positive treatment outcomes. The strength of the alliance has been estimated to account for 30% of the variance in treatment outcome (Lambert & Barley, 2002). There is little research on the relationship of alliance and treatment outcome in the child field, and the initial analysis of the existing studies did not demonstrate a robust correlation between outcome and therapeutic relationship (Shirk, S., & Karver, M., 2003). Karver and associates (2006) reviewed 49 studies (in which relationship was broadly defined) and found that the therapist’s use of interpersonal skills (e.g., warmth, empathy) and influence skills (e.g., presenting information clearly with rationale) were related to treatment outcome.
Kazdin and associates (2006) measured the strength of the therapeutic alliance in treatment conditions created between therapists and 77 oppositional, aggressive children enrolled in problem-solving skills training. The team also measured the strength of the parent-therapist alliance for parents who participated in parent management training. They found that the strength of the alliances was related to positive changes in the children and improvements in parent management skills and interactions in the home. As the field moves forward, it is likely that the relationship or alliance will be measured and validated as a critical component of therapy outcome.
In summary, in the child field, emerging research supports the contribution of the relationship and family involvement to treatment outcome. How the nurse psychotherapist forms an empathic bond with the child and creates agreement on the goals of therapy with families underscores all therapeutic efforts. Forming that relationship with the child in large part depends on the nurse therapist’s efforts to develop a bridge of empathy with the child’s meanings, meanings expressed by nonverbal behaviors and ones extracted from the youth’s narrative of experiences (DeSocio, 2005; Reynolds, & Scott, 1999).
Resiliency
Resiliency was initially conceptualized by means of a person-centered approach, isolating characteristics of children who were able to develop and thrive in the face of significant adversity (Anthony, 1987). Increasingly, resiliency is viewed as a grounding conceptual framework for intervention programs that promote competency and minimize stress (Masten & Powell, 2003). In line with this approach, interventions are not primarily focused on pathology but on strengths and promoting protective processes in families and systems that interface with the child (Masten & Powell, 2003; Selekman, 1997). A strength-based orientation moves beyond diagnosis-bound approaches to accommodations in the environment that will strengthen factors to help children and adolescents overcome the adversity they may face.
This emphasis has been part of child psychiatric nursing since the first standards of practice written in 1985 (ANA, 1985). It is also in line with the current SAMHSA (2005) orientation toward focusing treatment on building recovery and resiliency. This orientation does not discount diagnosis but emphasizes that nurse psychotherapists combine symptom amelioration with building environments that allow for the mobilization of a positive developmental thrust, a potential Emde (1990) believes resides in all children and is re-set in motion in an environment structured to support functioning.
This orientation does not discount the need to intervene to help children regulate or alleviate distress. Any psychotherapist treating children must also know a range of interventions and what is efficacious for the treatment of a particular serious emotional disorder (Ollendick & Davis, 2004). For instance, a child dealing with severe anxiety will more than likely need to learn regulation skills ground in cognitive-behavioral techniques (Kendell et al., 2003). It would be an error in clinical reasoning not to initially consider these techniques given the substantial evidence supporting the use of behavioral, cognitive-behavioral, and combined techniques (e.g., use of pharmacotherapy) in anxiety disorders (Ollendick & March, 2004). Chapter 6 provides an extensive explanation of cognitive-behavioral therapy (CBT) for adults and guidelines for conducting cognitive therapy sessions. The principles of cognitive therapy with children are similar; sessions are problem focused, collaborative, and goal oriented (Friedberg & McClure, 2002). However, as Friedberg and McClure (2002) point out, because of the child’s motivation for treatment and cognitive or verbal abilities, therapy tasks must be constructed in line with the child’s abilities, developmental level, and orientation to the “here and now.”
Alternately, part of building resiliency may mean addressing the pivotal process that may be driving the disorder. For example, the treatment plan for a depressed adolescent may need to include interpersonal psychotherapy (IPT) when dysfunctional relationships are seen as central to the disorder (Mufson et al., 2004). Chapter 7 contains an excellent outline of the principles and basic techniques of IPT and a summary of the accommodations of the model in IPT protocols designed for adolescents. Alternately, therapy may be focused on coping skills for a labile, impulsive youth whose broader issues with affect regulation are pivotal to the maintenance of the depression (Silk et al., 2003). Either or both processes (interpersonal and dysregulation) may be at play in adolescent depression, and treatment should address the core issue.
To build resilience, however, the nurse psychotherapist must integrate these EBPs with family’s goals and a plan for building competence, which may include adjustments to the child’s environment. Excellent examples of such strategies are provided in the literature (Herrick, 2006). In this model, a knowledgeable nurse case manager coordinates services between various agencies to meet the needs of a mother and her child, maintain family cohesion, and help the child re-engage with development (Herrick et al., 2006). Combining evidence-based therapy, a traditional deficit approach, with a fundamental strength-based framework may seem like forging a meeting of opposites. What is essential is that the nurse psychotherapist is able to weave together the targeted interventions within a plan for building systems that promote a child or adolescent’s competence. In doing so, the nurse aims to help the child get back on the developmental path of agency, choices, and eventually, self-efficacy (Basch, 1988).
Regulation
The third R in the 3R method has historically been defined according to rituals. Rituals in therapy have been seen as the vehicle for the experiential reorganization of self-defeating patterns (Mahoney, 2004). The idea of ritual runs deep in psychotherapy. It is a long-standing belief that in psychological treatment there must be some emotional arousal and insight. An alternate way to approach the idea of helping children and adolescents rests not necessarily with engagement in therapy rituals but with engagement in experiences that will help them reorganize, strengthen, and re-connect with developmental challenges. In doing so, children engage in life so they are “experiencing” making decisions that lead to behaviors that promote competence, which increase esteem (Basch, 1988). To re-engage with social systems, children must be able to respond to situations with appropriate control of their behaviors and emotions. This critical task is the final R in the scheme, represented by the notion of self-regulation.
At its most basic level, regulation is conceptualized as a developmental milestone of childhood with which the child can control behavior in the service of socially desirable conduct (Kochanska, 1993). As an example, think of the 4 year old who, as the preschool teacher puts down a plate of cookies, is told to wait for snack time to begin. What prevents that child’s hand from snatching a treat? Neuroscientists would argue that the restraint arises from the development of inhibitory control and the integration of emotion with memory (e.g., What happened last time I snatched a cookie?). These processes help dampen the rush to reward so that the child can comply with the teacher’s demand and wait. It is within this almost simultaneous action and reaction of cognitive, emotional, and motor systems that individuals adjust to the demands of a particular situation (Posner, 2004; Posner & Rothbart, 2000). Self-regulation theory concerns itself with the various processes at play when one system (e.g., cognitive, emotional) controls the reaction of another (e.g., motor) (Derryberry & Reed, 1996).
Self-regulation depicts the pivotal developmental process of integrating aspects of experience and reacting, and it has the potential to bridge psychotherapy and neuroscience. The future of child psychotherapy may lie in how neuroscience informs the process of creating experiences and surrounds such that the child builds new, adaptive neural pathways and new ways of thinking, feeling, and behaving (Schore, 2001; Stein & Kendall, 2004). The potential of self-regulation to work as a unifying concept in this psychotherapeutic process rests with three arguments.
First, self-regulation is increasingly understood to cut across several dimensions of child psychopathology. Difficulties with self-regulation are related to disorders such as ADHD, PTSD, depression, and anxiety (Shipman et al., 2000; Silk et al., 2003; Suveg & Zeman, 2004; Walcott & Landau, 2004; Zlotnick, Donaldson, Spirito, & Pearlstein, 1997). Problems in the preschool child’s self-regulation have been tied to subsequent issues with aggression, social withdrawal, and conduct problems (Calkins & Fox, 2002; Campbell, Shaw, & Gilliom, 2000; Cole et al., 2003). Because it may be one of the pivotal processes that drive several disorders, Racusin and associates (2005) suggest it should be a component of any therapy program aimed at attention, self-awareness, or cognitive work.
Second, self-regulation is a useful concept because, by definition, it involves the coordination of several systems involved with how children think, feel, and remember. Neuroscience research repeatedly illustrates how frontal lobe activities coordinate with limbic system structures to control attention and modulation of emotions, which facilitate a person’s ability to respond appropriately to particular situations (Calkins & Fox, 2002; Eisenberg & Spinrad, 2004). Conceptually, self-regulation integrates the cognitive, behavioral, and emotional components of personality (Derryberry & Reed, 1996), and as such, it is a gateway to a holistic view of how children and adolescents think, feel, and act.
Third, self-regulation is a useful concept because it allows correlation of higher-level cognitive function with brain systems (Posner & Rothbart, 2000). With the advent of advanced neuroimaging methods such as functional magnetic resonance imaging (fMRI), we can look inside the brain as it faces cognitive challenges. This knowledge of how the brain functions under challenge may in the future support studies that trace how therapy promotes the growth of prefrontal-amygdala connections (Grosjean, 2005) and the experience-dependent growth of key areas such as the right orbitofrontal system (Schore, 2003). The remainder of this chapter deals with the idea of helping children regulate, and it uses as a portal the emerging neuroscience of self-regulation.
Research Base for the Three R system: The Neuroscience of Self-Regulation
The notion of self-regulation, particularly how one system governs the reaction of another, can be illustrated with a clinical example that demonstrates how a dysregulated flight or fight mechanism can disturb the requisite integration of cognition and affect. The flight or fight cascade is presented in Chapter 2. Human beings are primed to scan the environment and to detect possible threats among other events. Integral to this in-bred process is the process of taking in social information (e.g., facial expressions). This largely cognitive process governs the reaction of the amygdala, the brain organ where threat is registered and fear generated. As children sense threat, the amygdala registers the warning and sends out messages to other brain organs to ready the body for a possible fight.
As individuals take in social information and respond emotionally, another regulator comes into play, the hippocampus, which brings to the fore past experiences that seem similar to the one facing the child. If these representations are experiences that registered fear, this recall process can upregulate the amygdala response and stimulate an alarm response. This additional component brings the hypothalamic-pituitary-adrenal (HPA) axis on board, and the hypothalamus excretes hormones to prepare the body for what it may be about to face (Shea et al., 2004).
How does this process become an issue of self-regulation? When fear and panic grow, maltreated children (already poor at reading facial expressions) narrow their information intake to key on the threatening aspects of the situation (Rieder & Cicchetti, 1989). They sharpen their senses to detect danger at the expense of taking in additional information (perhaps that the threat is over). This tight focus on fear distracts them from information relevant to the task at hand and decreases their initiative to seek information that may help them master the situation generating the threat (Pollak & Tolley-Schell, 2004). Rieder and Cicchetti (1989) proposed that this flaw in leveling and sharpening perceptions (i.e., in directing attention) cascades to influence other critical information processing tasks, such as understanding complex social situations and display rules. The neurobiology that lays the maltreated brain vulnerable to a poor stress response also introduces social information processing deficits that have wider developmental implications, particularly in the area of how these children direct attention (Pollak & Tolley-Schell, 2004; Teicher et al., 2002).
The neuroscience of self-regulation seeks to explain on a much broader scale how the mind directs attention and controls behavior so that youngsters appropriately respond to challenging situations. Posner & Rothbart (2000) propose that certain cognitive activities change brain circuitry, such as when children exert effort to shift attention and hone in on learning tasks. This attentional control is key to what a person attends to and facilitates how the information is stored in memory, laying the groundwork for representations, which play into regulation (Derryberry & Reed, 1996). For example, Derryberry and Reed (1996) argue that anxious children’s proclivity to overattend to anxious internal sensations and negative events may lead them to develop negative cognitive representations of the “world as dangerous,” representations accompanied by tense, negative emotions. This representational filter leads them to readily direct attention to threatening information in the environment, perpetuating their anxious style.
Attention control is an integral component of self-regulation, foremost by its role in effortful control. Effortful control (present beginning at about age 4 years) is the child’s capacity to direct attention and choose appropriate responses in challenging situations that require deliberate decisions (Lewis & Stienben, 2004). Effortful control is related to attention control because by voluntary shifts in focus, the child is better able to modulate his or her impulses, control thoughts, and plan behaviors and, in so doing, select strategies that will help her/him achieve a cognitively situated goal (Posner & Rothbart, 2000). Effortful control is thought to involve specific relay of impulses in an area of the frontal lobe, the anterior cingulate cortex (ACC). The ACC is a section of the frontal cortex whose dorsal portion is connected to the prefrontal executive function areas, thought to have most to do with cognitive controls and reward-based decision making. The more ventral portion of the ACC (i.e., perigenual cingulate gyrus) travels down to the limbic system and is involved with emotion control (i.e., processing emotional information, controlling the valence of emotions, motivation and ultimately regulation of autonomic and endocrine functions) (Bush, 2004) (see Chapter 2, Figure 2-5). The development of effortful control is complex, but suffice to say, it is related to temperament, infant experiences of attending, and parenting efforts to help children internalize rules and cultivate a cooperative orientation toward parental requests (Dennis, 2006; Kochanska et al., 2005).
The literature on the neuroscience of attention and its relationship to disease states is growing, placing the science at the edge of the practical application of research to treatment (Stevens, 2005). To illustrate the potential of the practical application of neuroscience, three areas are highlighted: inhibitory control, emotion regulation, and response flexibility. In the following section, each concept is explored with suggestions for how they may be linked to specific disorders of children and to more global areas of self-regulation deficits. Such application may alter the way nurse psychotherapists assess and attribute causality to behavior.
Within neuroscience, extensive literature exists on each of these ideas and the proposed neurobiologic mechanisms. As the literature grows, so to does the sophistication of examining these neurobiologic processes. Attempts to explain the state of the science in any one area would require detail beyond the scope of this chapter. It would also be difficult to explain, even for one disorder, all the factors that impinge on the development of neural functioning (Meyer et al., 2006). The focus is instead on how neuroscience has expanded understanding of the way cognitive and emotional systems simultaneously interact as individuals meet challenging tasks. The overriding concern is the practical implications of this research, particularly the potential for neuroscience to inform therapeutic work with children.
Inhibitory Control and Inhibition Failure
Children with ADHD have a fundamental problem with inhibition. Poor inhibitory control is seen as the core deficit of the disorder (Barkley, 1998), but the models that explain this impairment are quite diverse. Explanatory theories differ widely, from ones that focus on deficits in the child’s ability to stop or inhibit responses to ones that hold children with ADHD “hurry up” because they cannot tolerate the perceived delay (Tannock, 1998, Toplak et al., 2005). ADHD research is large and conflicted, leaving some researchers to argue that there is little hope of uncovering the target neural patterns that underlie specific cognitive processes (Swanson et al., 2004). Acknowledging these difficulties but in the interest of broadening understanding of self-regulation, I focus on recent studies that consider ADHD deficits in the context of interacting systems, such as the role of the ACC and the caudate nucleus in the child’s failure to inhibit.
The problems with ADHD have long been viewed as a fundamental problem with the connectivity between the prefrontal cortex, caudate, and globus pallidus (i.e., the striatal region) (Tannock, 1998). Scientists are beginning to understand how neuronal firing in the ACC that may contribute to a child’s ability to control behavior primarily because the ACC “motivational” firings direct attention to errors (Lewis & Stienben, 2004). In one study, researchers looked specifically at how the brain fired when children with ADHD failed to inhibit (Rubia et al., 2005). In such a situation, an examiner would expect the posterior portion of the cingulate to activate and let the subject know he had committed an error (Lewis & Stienben, 2004; Luu & Tucker, 2004). In this study, the adolescents with ADHD had reduced activation in that part of the cingulate (posterior), so that there was scant firing that alerted the teens to allocate attention after committing an error (Rubia et al., 2005). The study authors suggest that perhaps ADHD children’s reduced performance on executive tasks may be partially due to their failure to attend to and evaluate errors. The dorsal ACC is thought to be responsible for a host of self-monitoring activities, such as effortful evaluation, conflict monitoring, selection among competing responses, and feedback monitoring (Lewis & Stienben, 2004). The impulsivity of the ADHD child may be a function of failure to inhibit and failure to monitor errors and use feedback in response decisions.
To voluntarily constrain action demands sustaining focus, which means children must block out distractions (i.e., interference suppression) (Vaidya et al., 2005). Vaidya and associates (2005) demonstrated that when presented with a task requiring response inhibition and interference suppression, preadolescents with ADHD (versus comparison subjects) weakly activated different areas of the frontal cortex in attempts to inhibit. They also activated a different area of the brain in their efforts to suppress interference; during cognitive challenges, they failed to activate the caudate nucleus. Neural activity in the caudate is thought to help individuals encode event probability. Vaidya and associates (2005) concluded that multiple patterns of neural abnormality account for the problems with inhibition of ADHD children, but that the workings of the caudate nucleus may be key to understand the convergence of the two issues: response inhibition and interference suppression.
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