Case Formulation with Children and Adolescents

258 Pages·2014·4.58 MB·English

by  Katharina Manassis MD FRCPC

ebook
THE GUILFORD PRESS
Case Formulation
with Children and adolesCents
Also from Katharina Manassis
Problem Solving in Child and Adolescent Psychotherapy:
A Skills-Based, Collaborative Approach
Case Formulation
with Children
and adolescents
Katharina Manassis
The Guilford Press
new York london
© 2014 The Guilford Press
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Library of Congress Cataloging-in-Publication Data
Manassis, Katharina, author.
Case formulation with children and adolescents / by Katharina Manassis.
pages cm
Includes bibliographical references and index.
ISBN 978-1-4625-1560-8 (hardback : acid-free paper)
1. Psychiatry—Case formulation. 2. Interviewing in child psychiatry.
3. Interviewing in adolescent psychiatry. 4. Child psychiatry—Differential
therapeutics. I. Title.
RC473.C37M36 2014
616.89—dc23
2014003703
about the author
Katharina Manassis, MD, FRCPC, is Staff Psychiatrist and Senior
Associate Scientist at the Hospital for Sick Children in Toronto, where
she established and continues to work in the Anxiety Disorders Pro-
gram for children and youth. The program focuses on the develop-
ment and scientific evaluation of cognitive-behavioral treatments.
Dr. Manassis is also Professor in the Department of Psychiatry at
the University of Toronto and a member of the Human Develop-
ment and Applied Psychology Department at the Ontario Institute
for Studies in Education. These appointments allow her to supervise
graduate students, residents, and fellows in the treatment and study
of childhood anxiety. Dr. Manassis leads several funded research
studies to better understand and treat childhood anxiety disorders.
She is the author of more than 70 papers in professional journals in
this field and of two widely read books for parents, Keys to Parenting
Your Anxious Child and Helping Your Teenager Beat Depression, as well
as books for child mental health professionals, including Problem
Solving in Child and Adolescent Psychotherapy.
v

introduction
w
hen I began my training in child and adolescent psychiatry
in the 1980s, one of the first skills I was required to learn was case
formulation. That is, after interviewing a child or adolescent and his
or her family, I was expected to present to my supervisor a coherent
story of how this young person’s difficulties had come about. Then,
based on this story, I had to propose treatment(s) that would be help-
ful in ameliorating those difficulties. The starting point for the story
was a table listing various biological, psychological, and social factors
that might be contributing to the youth’s problems. I soon learned that
the same table of factors could be synthesized into multiple different
stories, depending on the interests and theoretical orientation of the
supervisor. In fact, clever and ambitious trainees would tailor the case
formulation to a supervisor’s preferences. Occasionally, I encountered a
supervisor who emphasized diagnosis over case formulation, but most
supervisors at that time dismissed diagnosis as “mere phenomenol-
ogy” and believed strongly in case formulation.
Over the years, discoveries in neuroscience and child development
have profoundly altered the nature of the factors used in case formula-
tion with children and adolescents. Clinicians have also increasingly
recognized the importance of cultural and spiritual factors in addition
to biological, psychological, and social ones. Although these develop-
ments have significantly changed the content of most case formula-
tions, the process of case formulation has not changed nearly as much.
vii
viii introduction
Clinicians must still carefully gather information from children, fami-
lies, teachers, and other professionals, and then synthesize the infor-
mation into a coherent story, use the story to inform treatment, and
communicate the story effectively to all concerned.
Revision of the case formulation in response to new information,
however, has received greater emphasis in recent years. The case for-
mulation is no longer seen as a definitive, unchanging explanation of
psychopathology but rather a hypothesis to be tested and modified over
time. This change makes sense, as mental health professionals on the
whole now take a more empirical approach to their work than they did
in the past. In other words, they are willing to concede that if a youth’s
behavior is inconsistent with their initial hypothesis, then maybe the
hypothesis was incorrect.
In addition, most mental health professionals no longer see diagno-
sis and case formulation as competitors. Instead, these two approaches
are seen as complementary, with each offering helpful perspectives on
the young person’s distress and therapeutic needs. Recently, the case
formulation approach has enjoyed renewed interest as clinicians have
appreciated the limits of relying solely on diagnostic categories. For
example, the dimensional approach to psychopathology in DSM-5 may
reflect the recognition that people present with complex mental health
issues that are not always amenable to neat categorization. Of course,
some classification of psychopathology is still important if we are to
communicate effectively about mental health and mental illness, but
when a young person doesn’t fit a particular category, it is important to
seek a more nuanced understanding of his or her symptoms.
Recent advances in child development and public education about
mental health have also renewed interest in case formulation. Develop-
mental psychopathologists are increasingly able to elucidate the com-
plex interplay between various risk and protective factors and between
various genetic and environmental effects. As a result, our efforts to
formulate children’s difficulties are becoming less speculative and
increasingly rooted in developmental science. Moreover, as families
are becoming more educated about their children’s mental health, they
expect clinicians to provide a holistic, developmentally sophisticated
understanding of their children in addition to an accurate diagnosis.
In short, the case formulation appears to be an old idea whose time has
come again.
On a practical level, the case formulation enhances mental health
care for children and adolescents. It is a systematic approach, reduc-
ing the chances of missing key pieces of information relevant to a