درمان اضطراب دوران کودکی:ابعاد رشد

This review focuses on research on the cognitive-behavioral treatment of childhood anxiety disorders. Early forms of therapy for childhood anxiety were borrowed from adult treatment models. More recently, there has been a recognition of the need to design treatment from a child-based perspective. Consequently, several cognitive-behavioral programs designed specifically for children and youth have been both developed and evaluated. The importance of parental involvement has also been recognised in these treatment innovations. However, a number of developmental factors have yet to be given adequate consideration in both the research and practice of childhood anxiety treatment. The article highlights some of these factors including issues of individual, family and cultural variation.

TREATMENT OF CHILDHOOD and adolescent anxiety has garnered increasing attention over the last decade. For the majority of children, anxiety is a common, functional, and transitory experience (Last, Perrin, Hersen, & Kazdin, 1996), the nature and intensity of which varies, at least in part, according to the child's developmental stage. For example, young children often experience anxiety when separated from main attachment figures or if exposed to dark, unfamiliar places. In comparison, the anxieties expressed by adolescents relate more commonly to social identification and interpersonal issues. Unfortunately, for a large proportion of children and adolescents, anxiety may increase in intensity, becoming chronic and developmentally dysfunctional. For these young people and their families, normal daily activities are usually disturbed and anxiety becomes a pervasive, intrusive problem requiring clinical intervention (Messer & Beidel, 1994). This is reflected in the fact that anxiety disorders are the most prevalent type of psychological disorder experienced by children and teenagers Albano, Chorpita, & Barlow 1996 and Bernstein & Borchardt 1991. Of further relevance to the present discussion is the observation that for those children and adolescents who experience chronic anxiety, but remain untreated, the prognosis is significantly poorer (Dadds, Barrett, & Cobham, 1997). Keller et al. (1992) assessed past and present psychopathology in 725 children and adolescents aged 6 to 19 years who were recruited in order to study the effects of parental affective illness on children. Fourteen percent of the children were found to have a history of an anxiety disorder, and of these children, only 34% were free of an anxiety diagnosis at the assessment period. The average duration of the disorder at the time of assessment was reported as 4 years. Other research noted that children with an anxiety disorder were still likely to fulfil diagnostic criteria up to 8 years after the onset of the disorder (Kovacs & Devlin, 1998). There is some indication, then, that childhood disorders may be more chronic and enduring than initially thought. Initial approaches to the treatment of childhood anxiety used elements and processes from adult treatment models, derived from adult-based theories, with terminology adapted for a youth population. In this regard, the childhood anxiety field is not unlike many others in clinical child psychology that have been built on the foundations of adult treatment paradigms. More recently, however, there has been a growing recognition of the need to consider developmental factors as they relate to the etiology, assessment, and treatment of various childhood disorders. Given the potential for anxiety problems to occur across the lifespan, as well as the established links between childhood anxiety disorders and psychological disorder later in life (Kovacs & Devlin, 1998), the application of a developmental perspective in the treatment of childhood anxiety seems warranted. The impact of developmental factors is further mediated by the cultural context and background of the family and society to which the young person belongs. One illustration is the observation that Portuguese children, from a nonclinical population, report more fears on average than do English children (Fonseca, Yule, & Erol, 1994). Moreover, a perusal of Portuguese research on parent–child relationships indicates that it is culturally appropriate for children as old as 7 years to sleep in their parents' bedroom; a custom that would find less favour within Anglo-Saxon-based cultures. It has been argued that a major failing of current clinical research is its dependence upon a culturally narrow (western, middle-class) definition of psychopathology and mental health (Kaslow & Thompson, 1998). A careful examination of practices in countries of non-English-speaking background would likely lead to a re-think of our culturally bound definitions of what is developmentally appropriate and what warrants clinical intervention. The aim of the current discussion, then, is more specifically to examine the relevance of developmental factors to the treatment of childhood anxiety, and in so doing, to argue for their consideration and inclusion in future clinical research and practice. A brief review of treatment literature currently existing in the child and adolescent anxiety field is included, as is a discussion of various, developmental issues related to treatment design and implementation.

Generally speaking, standardised treatment programs for childhood anxiety have only been designed and evaluated over the past 10 years. Research in this area has grown in accuracy and sophistication, with positive consequences for families and clinicians. However, in common with other areas of child and adult psychopathology, several conceptual and methodological limitations still remain. The current discussion has sought to highlight some of these, with particular emphasis on the developmental domain. One continuing controversy has to do with the very definition of “childhood anxiety disorder” (Gullone, 1996). This controversy impacts upon the assumptions that underlie our current models of psychopathology, and on the implications of these for assessment and treatment. Another issue is the role of the family and peer group in terms of increasing the efficacy of childhood anxiety treatment also needs further study. Furthermore, we do not yet have clear protocols, nor data about social validity and integrity procedures, for implementation of childhood treatments in general. Kazdin and Kendall (1998) have proposed a number of steps that should be taken in the development of any effective psychological treatment. These steps move through conceptualisation of the dysfunction; research on processes related to the dysfunction; conceptualisation of the treatment and its goals; specification of how the treatment is to be operationalised; tests of the treatment's outcome; tests of the treatment processes; to tests of the boundaries, conditions and moderators that affect the optimal implementation of the treatment. It seems appropriate that, where the treatment pertains to children or adolescents, consideration of developmental factors should be included at each of these steps. For example, it would be redundant to design a treatment protocol for children of different ages without having involved developmental considerations in the conceptualisation of that treatment. Similarly, to have made the effort to build developmental themes into a treatment design, yet fail to evaluate the effect of these themes on treatment outcome, would be to overlook information that is potentially critical to future treatment design and application. There appears no doubt that we need to develop new paradigms for childhood anxiety research, and that specific theoretical models must be formulated to account for the important developmental issues discussed throughout the discussion. Furthermore, as these issues encompass individual, family and wider-systemic variables, these potential models should not be restricted solely to explanations of developmental variation in the anxiety disorders themselves. Treatment needs, rather, to be informed by as many aspects of development as possible, and by the likely impact of these on the presenting client, rather than by diagnostic criteria alone (Sonuga-Barke, 1998).