Use of cbt in helping children experiencing nightmares, anxiety disorders and bipolar disorders
THE CASE OF 8 YEAR OLD ESTHER
The major issues that trouble 8 years old Esther are nightmares, anxiety problems and mood disorders. It is obvious from Esther’s family history that she shares the feeling of insecurity and depressive symptoms from her parents. The history of sexual abuse in the family makes her situation highly vulnerable.
Esther is in need of help to overcome her haunting nightmares and anxieties about herself and her beloved ones. She also needs support in overcoming mood disorders. The family environment also needs to be modified so as to give positive energy for the child to improve her cognitive and behavioural skills and to overcome her problems.
The theoretical approach that can help Esther in overcoming her issues more effectively is CBT. CBT techniques focus on cognitive areas and behavioural areas at the same time and therefore they are more effective in bringing out progressive changes in the subjects. CBT is a psychotherapeutic approach to find a solution to people’s emotional, behavioural and cognitive dysfunctions. CBT is recommended by NICE (National Institute for Health and Clinical Excellence) as an effective therapy for a number of problems like Post Traumatic Stress Disorder, Clinical Anxiety and Obsessive Compulsive Disorder (OCD) (http://www.wikepedia.org).
PART 1 – MAJOR ISSUES AND THEIR DESCRIPTIONS
NIGHTMARES AND DREAMS IN CHILDREN
Nightmares and emotions
American Psychiatric Association (DSM-IV-TR, 2000) and American Sleep Disorders Association (ICSD – II; International classification of sleep disorders: diagnostic and coding manual, 2005) define nightmares in association with the awakenings occur in the REM (Rapid Eye Movement) where the individual’s mental activities can be recalled so easily as the brain is active, even while the individual is sleeping. Nightmares do have some emotional component as well and which mostly associated with fear-, anger and disgust (Zadra A, and Donderi, D.C., 1994) among the various types of nightmares, idiopathic nightmares – the cause of which still remains unrevealed – are more severe and worrying.
Nightmares and developmental Process
Studies on children’s dreams and nightmares suggest that dreams and nightmares can be used to disclose the various developmental changes (Siegel, B. Allen, 2005). Children’s age is an important factor in their dreams that is their ability to remember and describe what they see in dreams. According to Siegel (2005), age affects children’s capacity to explain what they see in dreams and to link them with their day today life events. This study has pointed out that gender is the next important variable that affects dreams in children (Siegel, B. Allen, 2005).
Nightmares are generally are considered as part of the developmental process of children and adolescents and it does not need any treatment because they will cease to disturb them as their maturational process comes to its end (Terr L., 1987; Vela-Bueno A. et al,1985; Klackenberg,G., 1971). This view is supported by a range of literature of treatment of medical, psychological and psychiatric treatment of nightmares (Halliday, G., 1987). There are studies which prove that nightmares and dreams occur frequently in higher rates in children and adolescents. A recent meta-analysis by Sandoval, D. et al (1997) says that the occurrence of nightmares in children and adolescents very high, though the level varies at different stages of childhood and adolescence. They have found that the prevalence rate is higher in the early childhood category with 42.2 per cent. Another major finding of this study was that 42 per cent of the adults experiencing chronic nightmares had the problem onset by the age of 15 years and more than 50 per cent of the adult victims of chronic nightmares developed their problem before the age of 20 years. Even if nightmares are likely to decrease with the progress in maturational process, there are chances for them to turn out as disorders in some children and adolescents, due to a range of environmental factors that affect psychological balance like the death of a dear person, sexual or physical abuse or neglect by parents, carers, teachers, siblings, peers etc (Achenbach, T.M., 1981; Hartman, E., 1984). All these are evidences to the fact that children and adolescents experience nightmares in higher rates and chronic nightmares make a number of them to suffer, sometimes in their adulthood as well. Dreams and nightmares are normal but their interaction with unexpected and negative environmental factors – a few of them are listed before – affects the victims to make their life worse with chronic instances of nightmares.
Nightmares and Traumatic experiences
Traumatic experiences are found to have associations with nightmares. Most of the individuals with severe traumatic experiences can re-experience the event in the forms of nightmares and flashbacks. 75 per cent of the with post traumatic stress disorder (PTSD) experience the traumatic events in the forms of nightmares (Kilpatrick et al., 1994) and the rate of nightmare occurrence is higher in those who were traumatised by incidents like violence, rape and natural calamities. Krakrow et al (1995) conducted a study among the women who were diagnosed with PTSD after sexual abuse and assaults and found that 60 per cent of them were suffering from nightmares. Among them those women who survived rape were found to be suffering from higher frequency with 26 per cent.
Nightmares and Affect
There exists no scientific definition for dreams which is approved by everyone. Hence nightmares are interpreted as ‘unpleasant or frightening dreams’ (Pagel1, JF, Helfter, P., 2003). Nightmares have some negative affect in the individuals and it is this affect that causes disturbance or awakening during sleep (Zervas, I.M., Soldatos, C.R., 2005). Many efforts are made by applied scientists to explore the causes, mechanism and manifestations of dreams and nightmares in human beings (Soldatos CR, Paparrigopoulos TJ., 2005). Affect can be originated while a person is sleeping either by troubled homeostasis or through ‘the resynchronization of previously established affect-cognitive’ state (Georg Schulze, 2006).
Dreams and nightmares in children were always of higher importance among the researchers. Latest techniques likes content analysis research have become highly successful in explaining how dreams and nightmares in children can be used to read the effects of developmental changes in them. The task of analysing dreams in children in early childhood and childhood are difficult than the dreams of adolescents because the former group are less capable of recalling their dreams and to narrate them clearly (Siegel, B. Allen, 2005).
ANXIETY DISORDERS IN CHILDREN
Children and adolescents are no exceptions to anxiety disorders. Studies have found that 2.6-5.9 per cent of children experience overanxious disorder (OAD) and 2-5.4 per cent of them suffer from separation anxiety disorder (SAD) (Anderson, 1994). Anxiety disorders in children and adolescents have links with their language skills and thinking (cognitive) flexibility. Anxiety related disorders are not yet identified outside the verbal processes in Children (Toren, P., 2000). Different anxiety disorders and other psychological disorders have co-morbid relationships among them (Toren, P., 2000).
Anxiety Disorders and Neuro-cognitive functioning in children
Anxiety disorders in children and adolescents affect their neuro-cognitive functioning. Hooper and March (1995) and Benjamin, et al (1990) have identified that young children and adolescents with anxiety disorders are often noted by their teachers for poor academic performance. They suggest that this is the result of the neuro-cognition based learning disabilities in the children with anxiety disorders. There are no evidences for the relationship between childhood and adolescent anxiety disorders and brain dysfunction but it is found that anxiety can affect the adaptation skills of children and adolescents (Hooper and march, 1995).
Anxiety disorders have more specific and apparent impacts on the cognitive growth and development of children and adolescents. The studies using self-statement questionnaire have traced out the frequency, essence and depth of thoughts of children and adolescents with anxiety disorders; during and before performing tasks like writing (Kendall and Chansky, 1991). Eysenck (1990) has drafted a special scheme to understand the cognitive functioning of children and adolescents with anxiety disorders. The finding is portrayed as ‘threatening’ by Eysenck as he noted that children with anxiety disorders developed a sense of negative perception on themselves and the world around them. He has observed that the information processing system in such children operated so selectively with negative perception on themselves and the social environment. Children and adolescent with anxiety disorders shows a kind of biased processing of information with negative attitudes (Mogg, et al, 1993) and behaviour with ‘task-inhibiting thoughts’ (Francis, 1988). The negative attitude and perception on themselves, their tasks and on the whole society etc. are higher in children with higher anxiety related problems, when compared to their peers who had no anxiety related problems. It is also found that children experiencing anxiety disorders have difficulties in controlling their cognitive processes and attention on things they are doing. They are found to have difficulty to respond immediately in accordance with internal and external stimuli that make them to act properly with situational requirements (Kendall and Chansky, 1991).
Anxiety disorders are not specific to any specific period in human life but their prevalence is widely recognised to occur at any time in the lifetime of an individual (Kessler et al., 2005). Anxiety disorders affect not only the individuals who suffer them but at the same time they have gained a socioeconomic concern and at the same time there is shortage of information to explain the scope of anxiety disorders above the sphere of OCD (obsessive compulsive disorders) (Paul Hammerness, 2007).
The existing literature on childhood anxiety disorders were criticised for their limited information. Those studies were criticised for being conducted with limited samples and for limited techniques of data collection. And they failed to provide accurate information on individual syndromes by coming out of the broad areas. The research on childhood anxiety disorders is yet to come out of the traditional definitions that are limited to separation anxiety. It further needs to supply information about the disorders which have co-morbidity with childhood anxiety disorders. (Paul Hammerness, 2007).
The field of study of childhood anxiety disorders need to be fortified with relevant, scientific and clinical evidences so as to have more accurate findings on the causes and effects of those disorders. The co-morbidity factor of childhood anxiety disorders is yet to be explored in detail. It is inevitable for providing help and support to children who are clinically challenged with childhood anxiety disorders. Above all, these studies must be capable of providing inputs to public health knowledge base and strategy formulation for earlier interventions to address the issues related with childhood anxiety disorders (Paul Hammerness, 2007).
MOOD DISORDERS IN CHILDREN
Mood disorders are mainly classified into four types by the DSM-IV-TR (APA, 2000) namely ‘depressive disorders’, ‘bipolar disorders’ ‘mood disorders due to medical conditions’ and ‘substance-induced mood disorders. Children and adolescents with mood disorders suffer from a lot of personal, familial and social problems. Mood disorders affect children’s academic life and interpersonal relationships too (Duggal, et al., 2001). Mood changes are normal in various developmental periods with depressive and at times can be elevated too. The term ‘mood disorders’ is not used to mention these temporary mood fluctuations but the mood changes that last in them for a longer time and affect their day today life are part of mood disorders. mood changes that last in individuals for longer periods are considered as abnormal and they need special attention and treatment, depending on the functional impairment or disability of the individual (APA, 2000). Such functional impairments, if goes unnoticed, can harm the growth and development of children and can cause negative impacts on their academic performance, social and interpersonal activities (Reynolds & Kamphaus, 2003).
Among the victims of mood disorders, symptoms of depression are common to children and adolescents, before they attain adulthood (Ollendick, Shortt, & Sander, 2005). A recent meta-analysis by Costello et al (2006) has found that 2.8 per cent of the children under the age of 13 years suffer from depressive mood disorders whereas the prevalence rate is much higher in the adolescents in the age group of 14-18 years with 5.6 per cent. The study by Kessler et al (2001), which attempted to check the lifetime prevalence of mood disorders, has found that 25 per cent of adults with mood disorders have the onset of the disorder before attaining adulthood. Gender differences are quite visible in the matter of mood disorders. Studies have found that women are more vulnerable to depressive disorders during their adolescence (Cohen et al., 1993; Kessler et al., 2001). The ratio of depressive disorders in males and females during adolescence is 2:1 (Axelson & Birmaher, 2001; Rushton, Forcier, & Schectman, 2003).
There is literature evidence for the links between unipolar depression and personality traits. The symptoms of unipolar depression are higher rate of self-criticism, neuroticism and rigid behaviour (Sauer et al., 1997) and at the same time there is scarcity of literature to support the links between personality traits and bipolar disorder. Individuals with bipolar disorder are more vulnerable than those with unipolar disorders because bipolar disorder changes people’s mood unexpectedly and they are floated between low self-regulations, negative affectivity, decreased levels of cooperation etc. (Savitz and Ramesar, 2006).
PART 2. INTERVENTION WITH CBT
Esther is suffering mainly from haunting nightmares, anxiety disorders and mood disorders. The interventions that aim to support Esther have to focus these three important areas and have to understand the depth of the impacts caused by each of these problem areas. The approach we need to take is cognitive behavioural therapy approach which will help her to correct the accumulated wrong cognitions and perceptions which causes frequent nightmares, makes her worried about the safety and security of her own and that of her dear ones and to overcome the problems or issues due to depressive mood disorders.
CBT is the generally accepted and approved therapy for the treatment of psychological problems affecting children and adolescents. CBT is found to be effective in treating disorders called as internalising disorders like depressive disorders, anxiety disorders, OCD (obsessive compulsive disorder), ADHD (attention deficit hyperactive disorder) and CD (conduct disorder). These disorders are the result of gradual internalising processes that take place in the mind of the individual without he/she being aware of the changes they produce in him/her (Michael A. Southam-Gerow and Philip C. Kendall, 2000). These internalised perceptions and concepts are gradually revealed through different set of behaviours which are considered to be abnormal by the society and when they exhibit certain symptoms and signs of scientific definitions are considered to be disorders (Kendall et al., 1991; Kendall, 1993).
CBT FOR NIGHTMARES
The primary area of intervention for Esther is her nightmares. Using the CBT approach, the therapist needs to analyse her cognitive areas which are affected by her pathological condition. One approach that can be used to help Esther is the “auto-suggested dreams” approach (Wile, 1935) which asks children to dream about the coming night. This technique is to be exercised on a regular interval and it will produce remarkable improvements in the children, within few weeks or months, depending on the severity of the nightmare problem they experience. This technique needs to be followed up for at least 4-5 months to have the expected output (Barry Krakow, M.D., 2001). Another technique propounded by Barry Krakow is the imagery rehearsal therapy which involves four group therapy sessions, each of which lasts for 2-3 hours. Where the individual’s dreaming process is observed in a therapeutic environment and rehearsed so as to correct the problems there (Barry Krakow, M.D., 2001).
CBT FOR ANXIETY DISORDERS
The next problem that affects Esther is her anxiety disorders. CBT is widely used in the treatment of anxiety disorders in children and adolescents. Childhood anxiety disorders are caused mostly by the environment where the child lives, which involves their peers, their academic institutions their families and the low psychological wellbeing (Costello, Egger, & Angold, 2004; Verduin & Kendall, 2008). It is found that about 18 per cent of children and adolescents are affected by childhood anxiety disorders (Kessler, Chiu, Demler, & Walters, 2005).
CBT is used to be an effective therapeutic approach for childhood anxiety disorders. (Silverman, Pina, & Viswesvaran, 2008). It is also reported that the effects of CBT last for longer periods in children with childhood anxiety disorders (Glantz et al., 2009; Kendall & Kessler, 2002; Kessler et al., 2007). The effects of randomised controlled trials of CBT are said to be long-lasting and highly effective in helping children to get rid completely of their problems (Kendall, Flannery-Schroeder, Safford, & Webb, 2004).
CBT FOR MOOD DISORDERS
The next important area where Esther needs assistance is in controlling her mood related problems. CBT is highly effective in children experiencing mood disorders. The role of family, especially that of parents is highly important in using CBT in children with mood disorders, which was not recognised earlier (Lewinsohn, Clarke, Hops, & Andrews, 1990). In the modern CBT environment for children with mood disorders, parents are made aware with the skills, techniques etc. which are necessary for the treatment of the problems of their children. Parents’ support and involvement is found to be more effective in bringing out the expected changes in children who experienced childhood mood disorders and have undergone CBT Training. Both parents and children received benefits of latest technique of CBT. Esther’s parents also have to be included in the treatment process because the mood disorders are passed to her through both her parents who experience similar moods in the place where they live.
The therapist who intervenes with Esther has to pay special attention to the environment where she lives. The case hits that her parents too need to be observed for mood related problems. Therefore they too must be incorporated with the therapeutic process so as to ensure the effectiveness of the therapeutic approach with Esther. The family environment needs to be modified for longlasting effects.
Next area that needs attention is the protection of the child from sexual abuse from the maternal step-grandfather. As her mother and aunt are already victims of his abuse, the situation of Esther is highly vulnerable. She needs to be protected from him and her parents must be educated about this issue.
The case of Esther is of Nightmares, mood disorder and childhood anxiety disorder. The therapist can help her to overcome her problems through the effective use of CBT separately for all the problem areas where she suffers. Added to this her family environment which makes her maladjusted and feel insecure needs to be modified with proper education and awareness to the parents.
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