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Unread March 9th, 2006, 07:15 AM
leeman leeman is offline
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Default Children and Personality Disorders

I am wondering about research and evidence in relation to personality disorders in children and adolescents.

Does such a diagnosis exist? Are conduct disorders a euphemism for personality disorders in children and adolescents? Does Beck et als. book on CBT and Personality Disorders hold sway when working with children/adolescents?

Has anyone any ideas, particularly in relation to formulation and treatment of these diagnoses.

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Unread March 13th, 2006, 09:36 PM
James Pretzer James Pretzer is offline
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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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Unread March 16th, 2006, 01:06 PM
leeman leeman is offline
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Default Re: Children and Personality Disorders

Thanks James,

I have to make a CPD presentation and felt this may be an interesting topic particularly in relation to working with children in residential care. I wasn't too sure about the possibility of using CBT for personality disorder strategies with such a population.

I am guessing the point of any intervention in the child/adolescent population is to interrupt the development of schemas that are negative and dysfunctional before they become standard methods of interacting with the world. My only question is to know when these schemas are pervasive and persistent.

The aim of working with the family is key to treatment but it is difficult if the family system is a maintaining factor. What recommendations would you suggest for a passive-aggressive approach to change in an adolescent?
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Unread March 22nd, 2006, 10:09 AM
James Pretzer James Pretzer is offline
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Default Passive-aggressive behavior in an adolescent

With passive-aggressive behavior in general, the problem is that the individual expresses anger indirectly or in disguised ways. When this is the case, I'd generally want to start by developing an understanding of the individual's expectations regarding the likely consequences of dealing with anger and conflict more directly and actively. If they have unrealistic fears about the consequences of dealing directly with anger and conflict, then it can be important to challenge these expectations (possibly through behavioral experiments). It also can be important to help them find adaptive ways of dealing with anger and conflict (perhaps appropriate assertion), to help them recognize the drawbacks of their old ways of dealing with anger, and to address dysfunctional cognitions that result in unnecessary anger.

With passive-aggressive personality disorder, all of these interventions apply but it is also important to identify sources of chronic anger and to address them. If the individual has been trying to suppress all anger, this can easily result in chronic resentment and occasional angry outbursts. If the individual has strong convictions about how they "should" be treated by others, chronic anger can result when these expectations are not met. Likewise, if the individual operates on the basis of a unilateral contract "I've done ________, therefore they should _____________.", this also can easily result in chronic anger.

In an adolescent, all of these interventions can be useful but it can be important to pay much more attention to the family context:
  1. What messages about anger has the child grown up with?
  2. What examples has the child grown up with regarding how to deal with anger and conflict?
  3. What are the parents' beliefs regarding how children should handle anger?
  4. How will the family respond if the child tries dealing with anger more directly or if the child tries being appropriately assertive?
  5. Is the child being treated in ways that result in chronic anger?
  6. etc.

It can be very difficult, if not impossible, to deal effectively with passive-aggressive behavior if it is not possible to engage the family in treatment as well. In particular, if the family environment played an important role in the development and maintainence of the behavior, it will be quite difficult to change the behavior unless it is possible to make some lasting changes in the environment.
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