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Old March 13th, 2006, 09:36 PM
James Pretzer James Pretzer is offline
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Join Date: Jun 2004
Posts: 283
Default Re: Children and Personality Disorders

While children and adolescents may seem to have personality disorders, DSM's stance is that one shouldn't be routinely diagnosing personality disorders in children or adolescents. DSM-IV says "Personality Disorder categories may be applied to children and adolescents in those relatively unusual instances in which the individual's particular maladaptive personality traits appear to be pervasive, persistent, and unlikely to be limited to a particular developmental stage or an episode of an Axis I disorder. ... To diagnose a Personality Disorder in an individual under age 18 years, the features must have been present for at least one year" (emphasis added). There are a variety of reasons for not diagnosing personality disorders in children and adolescents.

First, while it is not unusual to observe behaviors in adolescents which seem very similar to those observed in adults with Axis II diagnoses, these behavior patterns often are much less stable than would be expected of a personality disorder. An adolescent may seem very "borderline," very antisocial, or very narcissistic today but that does not necessarily mean that they will still be the same in a few months. While transitory dysfunctional behavior can be a serious problem, this is not a personality disorder.

Second, peers and family often have a stronger influence on children and adolescents than is the case with adults (though it is important to pay attention to peer and family influences with adults as well). In many settings an adolescent who starts cutting is quickly labled borderline on the basis of that behavior alone. However, an adolescent who engages in superficial cutting in an attempt to fit in with peers, in attempt to get attention from parents, or in an attempt to manipulate parents is likely to be quite different from an adult who has a long-standing pattern of self-mutilation (and self-mutilation alone does not qualify one for a diagnosis of BPD).

Third, an Axis-II disgnosis can stick with a person for a long time and can have a major impact on how the person is treated by the mental health system, the healthcare system, and the insurance industry. It is not good to carelessly put a label on a kid when that label may have a negative impact for years. Conduct Disorders are not Personality Disorders. If you take a look at DSM you'll see that the diagnostic criteria are quite different and we treat them quite differently.

Having said all that, some of the interventions presented in Cognitive Therapy of Personality Disorders can be useful in children and adolescents, just as they can be useful on occasion with individuals who do not have personality disorder diagnoses. I'd recommend starting with a good assessment that covers the family, peer, and school environment rather than just focusing on the identified patient and considering whether CBT with the family might be more appropriate that individual therapy for the kid. After all, I'm going to have to be an awfully good therapist if my hour a week is going to outweigh the impact the family has the rest of the week.

If individual therapy for the kid is called for, I'd start with good CT adjusted for the kid's developmental level and perhaps add a few selected interventions from Cognitive Therapy with Personality Disorders. I would focus primarily on 1) establishing family interactions that reinforce adaptive behavior and meet the developing child's needs, 2) establishing effective discipline that minimizes the parent's reliance on punishment, 3) helping the kid effectively anticipate consequences, control impulses, and make good choices, 4) helping the kid find adaptive ways to cope with affect (including attention to dysfunctional thoughts). Most of the time, this will clear up problems in children and adolescents that look like personality disorders. Occasionally, when the problems are long-standing and ingrained interventions designed for treating personality disorders will be needed.

I hope this is helpful. I'd encourage you and others to post additional questions and comments.
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