Counseling Children and Adolescents, 1st edition By Victoria E Kress Test Bank

Type:

Test Bank

Counseling Children and Resource: Adolescents Edition:

1st Edition

Author(s):

Victoria E. Kress Matthew Paylo Nicole Stargell

Test Bank For

Counseling Children and Adolescents 1st Edition Victoria Kress, Youngstown State University Matthew Paylo, Youngstown State University Nicole Stargell, University of North Carolina, Pembroke

Prepared by Amy E. Williams, Youngstown State University

Introduction This test bank contains multiple-choice questions for each chapter in the Counseling Children and Adolescents, 1st edition text. These questions may be used to: •

Assess student comprehension of chapter readings

•

Measure change in knowledge from the beginning to the end of the course (pre-/post-test)

•

Guide students’ focus when reading (as an advance organizer)

•

Practice test-preparation strategies for professional examinations

Questions are organized by text chapter and focus on knowledge and application of chapter content. Answer keys are provided at the end of this resource.

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Table of Contents Chapter One: Developmentally Informed Youth Counseling

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Chapter Two: Systemically Informed Youth Counseling

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Chapter Three: Individual Counseling Foundations

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Chapter Four: Ethical and Legal Foundations

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Chapter Five: Counseling Theories That Focus on Thought and Behavior Change and Action

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Chapter Six: Counseling Theories That Focus on Background Experiences and Relationships

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Chapter Seven: Counseling Theories That Focus on Family Change Processes

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Chapter Eight: The Use of Play and Creative Arts in Counseling

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Chapter Nine: Conceptualizing Young Clients’ Situations and Directing Counseling

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Chapter Ten: Youth Suicide, Self-Injury, and Homicide

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Chapter Eleven: Family-Related Transitions and Struggles

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Chapter Twelve: Academic and Social/Emotional Transitions and Struggles

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Chapter Thirteen: Neurodevelopmental and Intellectual Impairments

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Chapter Fourteen: Disruptive Behavior Problems

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Chapter Fifteen: Abuse and Trauma

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Chapter Sixteen: Substance Abuse

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Chapter Seventeen: Anxiety, Obsessive-Compulsive, and Related Disorders

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Chapter Eighteen: Depressive and Bipolar Disorders

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Chapter Nineteen: Physical Health-Related Counseling Issues

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Answer Key

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Chapter One: Developmentally Informed Youth Counseling 1. Approximately ________ percent of mental health disorders develop prior to age 14. a. 10 b. 20 c. 50 d. 70 2. Youth development is: a. Consistent and predictable. b. Similar for all youth c. Slow and predictable d. Influenced by context 3. A milestone that differentiates adolescence from childhood is the development of: a. Abstract thinking b. Problem-solving skills c. Awareness of emotions d. Awareness of self 4. Insight is a typical developmental milestone of: a. Early childhood b. Middle childhood c. Early adolescence d. Later adolescence 5. Trauma is considered a developmental: a. Protective factor b. Risk factor c. Resiliency factor d. Both A and C 6. Academic engagement is considered a developmental: a. Protective factor b. Risk factor c. Resiliency factor d. Both A and C 7. One example of a cognitive risk factor is: a. Low intelligence b. Rebelliousness c. Poor physical health d. Poverty 8. One example of a psychosocial protective factor is: a. Humor b. High intelligence c. Secure attachment d. Empathy 1 ..

9. A 13-year old female client reports increasing mood swings, depression, and irritability. This is most likely to be a byproduct of: a. Puberty b. Social rejection c. Family conflict d. Poverty 10. A ten-year-old child who apologizes to a peer after an argument but who cannot describe what the peer was feeling during the argument is demonstrating characteristics of the ________ stage of development. a. Sensorimotor b. Preoperational c. Concrete operational d. Formal operational 11. A child who is able to empathize with others and think abstractly is most likely in the ________ stage of development. a. Sensorimotor b. Preoperational c. Concrete operational d. Formal operational 12. Attachment in early childhood provides a foundation for: a. Physical development b. Self-development c. Cognitive development d. Emotional development 13. A child who demonstrates confidence in relationships with peers and adults demonstrates resilience in the ________ domain: a. Physical b. Psychosocial c. Cognitive d. Emotional 14. A first-grader reacts to frustration in school by pounding her fists on the desk. This is most likely an emotional expression the student learned from a: a. Parent b. Peer c. Teacher d. Counselor 15. A baby who is born to a mother over the age of 35 may be at increased risk of: a. Down syndrome b. Lead exposure c. Developmental delay d. Cortisol exposure

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16. A child who feels positively about his social relationships but negatively about his academic accomplishments is demonstrating differences in ________ in these two areas. a. Self-esteem b. Self-concept c. Temperament d. Affect 17. Temperamental dimensions include each of the following except: a. Sociability b. Positive affect c. Fear/inhibition d. Euphoria 18. A child who independently engages in drawing, coloring, or other creative activities is likely in Erikson’s stage of: a. Trust versus mistrust b. Autonomy versus shame and doubt c. Initiative versus guilt d. Industry versus inferiority 19. In early childhood, mental health issues are most likely to be expressed through: a. Verbal expression b. Behavioral problems c. Poor peer relationships d. Poor parent-child relationships 20. A child whose temper tantrums increase during the first week of kindergarten is most likely reacting to: a. A traumatic experience b. A significant transition c. A poor parent-child relationship d. A conflict with peers 21. When working with young children, a counselor should do all of the following except: a. Attend to the child’s basic needs during the session b. Integrate the family into counseling whenever possible c. Stand over the child to avoid joining the child on his/her level d. Allow children to take an active role in the counseling process 22. During middle childhood, children’s growth becomes more: a. Predictable b. Consistent c. Variable d. Disorganized

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23. The prefrontal lobe of the brain develops dramatically during: a. Early childhood b. Middle childhood c. Early Adolescence d. Later Adolescence 24. A young person who describes himself by stating, “I have red hair, blue eyes, and I like karate,” is most likely in the stage of: a. Early childhood b. Middle childhood c. Early Adolescence d. Later Adolescence 25. Youth in middle childhood typically formulate a sense of self by: a. Taking on parents’ likes and dislikes b. Learning from media sources c. Comparing themselves to peers d. Avoiding activities enjoyed by siblings 26. Friendships in middle childhood: a. Involve supportive behaviors b. Are defined by self-interest c. Provide limited emotional support d. Are less important than early childhood friendships 27. Challenges that counselors may encounter with clients in middle childhood include each of the following except: a. Coping with transitions b. Managing independence c. Social skills d. Substance use 28. The ability to engage in goal-setting and planning in counseling for children in middle childhood is influenced by increasingly complex: a. Physical development b. Social development c. Cognitive development d. Emotional development 29. Behavioral concerns can be managed in middle childhood through the use of: a. Corporal punishment b. Deprivation of privileges c. Social isolation d. Shame and embarrassment

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30. An adolescent you are working with reports that she was punished for skipping class last week. When asked about this behavior, she states, “I really didn’t think I’d get caught.” This is an example of adolescents’ tendency to: a. Engage in oppositional behaviors b. Fail to foresee consequences c. Focus on self-interests d. Intentionally test limits 31. A client you are working with states that he is interested in becoming a teacher because both of his parents and all of his grandparents were also teachers. This is an example of: a. Identity foreclosure b. Identity diffusion c. Identity moratorium d. Identity achievement 32. Early adolescents are most likely to rely on their ________ when formulating values and beliefs. a. Parents b. Teachers c. Siblings d. Peers 33. During adolescence, clients and their families would most benefit from education on: a. Rules and consequences b. Parental dynamics and sibling relationships c. Sexuality and peer relationships d. Homework and academic success 34. A desire to be unique typically emerges during: a. Early Childhood b. Middle childhood c. Early Adolescence d. Late Adolescence 35. A young person you are counseling describes that his mood swings have become more manageable but that he is worried that he doesn’t stand out and doesn’t stand for anything important. He also reports infrequent marijuana use. This young person is most likely in the stage of: a. Early childhood b. Middle childhood c. Early adolescence d. Late adolescence

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Chapter Two: Systemically Informed Youth Counseling 1. When working with a young person, context may include all of the following except: a. Culture b. Development c. Gender d. Diagnoses 2. When considering cultural contexts for working with youth, counselors should: a. Assume that all clients from the same culture have similar values b. Explore how culture influences the client’s beliefs related to help-seeking c. Avoid discussing culture unless the client introduces the topic first d. Minimize the influence of culture on a young person to increase resilience 3. Which of the following is an example of a microaggression? a. A counselor greets a young Caucasian client with a handshake b. A counselor attends a meeting at school with a Caucasian client’s parents after obtaining written consent c. A counselor praises a young African American client for being articulate d. A counselor consults with an African American client’s pastor after obtaining written consent 4. A strengths-based approach to counseling involves: a. Focusing on clients’ strengths, previous successes, and resilience b. Relying on outside systems to promote client success and resilience c. Highlighting past failures to motivate the client the change d. Using reinforcers and punishments to promote client change 5. When working with a young client, a counselor encourages the client to set goals for the session and to select an assignment to complete for between-session homework.

This counselor is building resilience by promoting: a. Social competence b. Problem solving c. Autonomy d. A sense of purpose 6. A counselor works with a client to explore how the client can develop new friendships at school and in the after-school program she attends. This counselor is building resilience by promoting: a. Social competence b. Problem solving c. Autonomy d. A sense of purpose 7. Family risk factors include: a. Lack of financial resources b. Negative interactions with peers c. Community-based violence d. Racism/prejudice 6 ..

8. School risk factors include: a. Domestic violence b. Bullying c. Drug and weapon availability d. High residential mobility 9. Community risk factors include: a. Limited parental involvement b. Delinquent peer influences c. School violence d. Drug and weapon availability 10. Family protective factors include: a. Positive peer influences b. Expressions of warmth c. Motivation to achieve d. Leadership opportunities 11. School protective factors include: a. Positive peer influences b. Strong cultural identity c. Social and sports clubs d. Religious values 12. Community protective factors include: a. Leadership and volunteer opportunities b. Consistent and reasonable discipline c. Trusting friendships d. Motivation for achievement 13. When defining family as it relates to a client, a counselor should: a. Include all family members that are known to the counselor b. Focus only on family members living in the child’s household c. Include only biological relatives as family members d. Use the child’s subjective definition of family 14. A young client has been experiencing stomachaches, avoidance of school, and decreased appetite as a result of the recent birth of a younger sibling in the family.

This response is considered: a. A sign that the child is at increased risk of mental health disorders b. An indication that the child is angry at his parents c. A reasonable response to sudden change in the family system d. An indication of poor attachment in early childhood 15. According to Olsen, family roles and rules are most effective when they are: a. Predictable and flexible b. Predictable and inflexible c. Unpredictable and flexible d. Unpredictable and inflexible 7 ..

16. To accurately assess communication styles in families, the counselor should: a. Ask parents directly about how they communicate b. Observe family communication while discussing a range of topics c. Have the child draw a picture of how the family communicates d. Have the family complete a self-report assessment 17. Family factors that may negatively impact youth include all of the following except: a. A sibling with a mental or physical health disorder b. Overindulgence of the child c. Parents’ role as caregivers for their parents d. High expectations for academic success 18. Among the 3.5 million reports of child maltreatment, ________ percent involved allegations of neglect. a. 20 b. 40 c. 60 d. 80 19. Which of the following is true about child maltreatment? a. All children respond in similar ways to abuse or neglect by primary caregivers b. A child’s response to abuse or neglect is not influenced by the severity of the maltreatment c. Most children will experience secondary traumatic responses including feelings of helplessness and post-traumatic stress disorder d. Children who experience maltreatment often adapt and live healthy and productive lives 20. Which of the following is true about intimate partner violence and youth? a. Youth who are not physically involved in violence in the home are still likely to experience serious emotional consequences. b. Youth who witness intimate partner violence are less likely to bully peers or siblings c. Most mental health interventions for addressing the impact of intimate partner violence on youth are ineffective d. Only children are at decreased risk of being emotionally impacted by intimate partner violence 21. A counselor is working with an adolescent who states that, “My parents think school is dumb. I’m going to quit school and get a job so I can start helping with bills.” In the long term, this child’s choice may lead to: a. Increased self-esteem stemming from work experience b. Clear identity stemming from work experience c. Decreased career opportunities later in life d. Increased educational attainment later in life

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22. When considering the relationship between school climate and youth resilience, it is important to note that: a. Family conflicts do not influence school performance b. Negative experiences in school rarely impact family relationships c. Messages from teachers about capabilities often influence youth beliefs and attitudes d. Inconsistent rules in school rarely lead to youth behavior problems or concerns 23. Factors that may increase the risk of bullying behaviors include all of the following except: a. High IQ b. Substance use c. History of victimization d. Learning disorders 24. Factors that may increase the risk of school violence among youth include all of the following except: a. Substance use b. Poor family boundaries c. Poverty d. Weapons in the home 25. A counselor working with a young person who lives in a high-risk community environment would benefit from: a. Avoiding discussing issues of diversity and discrimination to avoid provoking emotions b. Encourage the family to relocate to a more stable community c. Promote engagement of the youth and family in clubs, sports, or activities that promote resilience d. Explain that some factors are uncontrollable and teach acceptance to the young person 26. In communities with neighborhood violence and crime, youth: a. Are likely to benefit from mentorship from positive role models b. Are unlikely to be protected by family safety and support c. Are unlikely to be influenced by peer behaviors d. Are likely to be protected by avoiding extracurricular activities 27. When it comes to technology, youth: a. Are unlikely to be influenced through social media b. Experience isolation if excessive time is spent online c. Have limited access to information that informs learning d. Derive little benefit from using technology and social media

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Chapter Three: Individual Counseling Foundations 1. The best predictor of positive counseling outcomes is: a. Client motivation in the first session b. A strong counseling relationship c. Client adherence to treatment d. A clear theoretical orientation 2. A counselor who conveys sincerity and empathy to clients demonstrates strong: a. Interpersonal skills b. Self-awareness c. Sensitivity to diversity d. Awareness of research 3. A counselor who is effectively monitoring client progress must: a. Use standardized assessment instruments b. Administer surveys after each session c. Consistently check in with clients regarding progress d. Statistically analyze changes in assessment scores 4. Effective counselors do all of the following except: a. Address difficult counseling topics b. Display sensitivity to diversity c. Adhere firmly to counseling plans d. Develop a strong working alliance 5. A counselor who works with young children would be most likely to have which of the following in the counseling office for use with clients? a. Books from counseling courses b. Handouts describing CBT c. A couch up against the wall d. A single bright overhead light 6. When considering whether to have snacks available for clients, counselors should ensure: a. Parents have consented to snacks b. Clients have access to favorite snacks c. Parents also are provided with snacks d. Clients also take snacks home for siblings 7. With regard to limits and boundaries, counselors should: a. Avoid structuring sessions to promote creativity b. Avoid predictability to promote client flexibility c. Adhere to a consistent structure to promote security d. Adhere to an inflexible structure to promote discipline

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8. A counselor begins working with a young client who resides with both biological parents. In order to obtain informed consent, the counselor should: a. Meet with the client on-on-one to obtain informed consent b. Meet with the mother on-on-one to obtain informed consent c. Meet with the parents together without the child to obtain informed consent d. Meet with the mother, father, and child together to obtain informed consent 9. Which of the following is true about assessment? a. It is a one-time event that occurs at intake b. It requires using standardized tests c. It occurs throughout the counseling process d. It rarely involves discussions with young clients 10. Which of the following approaches may help counselors understand what clients would like to be different in their lives during the intake process? a. Cognitive-behavioral therapy b. Solution-focused therapy c. Person-centered therapy d. Family therapy 11. In order to formulate a diagnosis of a four-year old child, a counselor is least likely to gain useful data using: a. Standardized observation protocols b. Client interviews c. Parental interviews d. School records 12. When working with youth, it is important to discuss both client and counselor expectations with: a. Youth only b. Parents only c. Youth and parents d. None of the above 13. Information that should be discussed regarding client and counselor expectations includes all of the following except: a. How long sessions will last b. How often sessions will occur c. How the counselor ensures client change d. How managed care might impact counseling 14. Explaining the purpose of play in counseling is: a. Not likely to be helpful for young clients b. Required by state licensure laws and ethical codes c. Important only when working with at-risk youth d. Helpful for promoting parental understanding

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15. With regard to meeting with parents, it is encouraged that counselors: a. Avoid meeting with parents without the child present b. Meet with parents alone then meet with the family together c. Avoid meeting with the child with the parents present d. Meet with parents alone at the end of the session 16. At the end of a counseling session, it would be most helpful for a counselor to: a. Administer a session rating survey b. Provide snacks to the client c. Reward the client with a treat d. Meet with the parents alone 17. A counselor who sets goals and objectives for a client without seeking client input may negatively be impacting the: a. Working alliance b. Focus of counseling c. Parent-child relationship d. Options for intervention 18. Developing a working alliance is especially important when working with: a. Youth who are struggling in school b. Youth who are mandated to attend counseling c. Youth who live in single-parent households d. Youth who have limited social supports 19. It is most important to attend to ________ in the early stages of counseling. a. Setting goals and objectives b. Establishing clear, firm structure c. Exploring clients’ emotions and interests d. Assigning a mental health diagnosis 20. Marcia’s adolescent client comes to session each week and states, “I don’t want to be here, this is dumb.” Marica could best address the client’s reluctance by: a. Avoid acknowledging the client’s resistance and proceed with the session b. Validate the client’s resistance and explore how best to use the session c. Contact the client’s parents to tell them about their child’s resistance d. Terminate with the client due to client noncompliance 21. In contrast to the preliminary stage of counseling, the working stage of counseling: a. Focuses more on assessment and data collection b. Is more similar across practitioners and settings c. Is more tailored to client concerns and counselor orientation d. Focuses more on developing the working alliance 22. Which of the following is most likely to promote verbal communication with clients? a. Question stacking b. Open-ended questions c. Closed-ended questions d. Art therapy techniques 12 ..

23. A client who states, “It’s not my fault. Everyone else has the problem, not me,” is most likely in the ________ stage of change. a. Precontemplation b. Contemplation c. Preparation d. Action 24. A client who states, “I know it’s a problem, but I don’t really know if I’m ready to do anything about it,” is most likely in the ________ stage of change. a. Precontemplation b. Contemplation c. Preparation d. Action 25. A client who states, “I turned all of my homework in for three weeks in a row,” is most likely in the ________ stage of change. a. Precontemplation b. Contemplation c. Preparation d. Action 26. The foundations of MI include each of the following elements except: a. Autonomy b. Collaboration c. Evocation d. Patience 27. Natural termination occurs when: a. Clients’ insurance stops paying for counseling sessions b. Clients stop attending counseling without warning c. Clients achieve their goals and all parties agree to end counseling d. Clients have completed the mandatory number of sessions 28. Signs of termination readiness include all of the following except: a. Missing scheduled counseling sessions b. Going deeper into emotions each week c. Scheduling more time in between sessions d. Experiencing setbacks after discussing termination 29. To prepare clients for the possibility of recurring concerns after termination, a counselor should: a. Refer clients directly to another counselor prior to termination b. Avoid terminating with clients so problems cannot reoccur c. Work with clients to create a maintenance plan d. Continue checking up on clients weekly to ensure progress

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30. Potential causes of premature termination include all of the following except: a. Transportation concerns b. Completion of treatment goals c. Geographic relocation d. Insurance changes 31. To decrease the likelihood of premature termination, counselors should: a. Explain requirements for completing counseling during the informed consent process b. Contact insurance companies of clients to report failure to complete treatment c. Communicate expectations to clients and family members early in counseling d. Refer clients who are at risk of premature termination to another counselor 32. Which of the following situations warrants a referral to another counselor? a. A client successfully completes a social skills group in at a mental health agency b. A student with chronic depression moves to a new school district near the end of the year c. A family decides to end family counseling due to accomplishing their goals and objectives d. A client is transferred to a higher level of care due to increased anxiety symptoms

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Chapter Four: Ethical and Legal Foundations 1. Enactment of laws in all 50 states requiring all professionals to report cases of child sexual abuse occurred in: a. 1956 b. 1966 c. 1976 d. 1986 2. According to the ACA Code of Ethics, when counseling minor clients, counselors should: a. Include parents in the counseling process b. Obtain written client consent to consult with parents c. Avoid consulting with parents to avoid triangulation d. Provide written updates to parents weekly 3. The term minor refers to youth who are: a. Under age 16 b. Under age 18 c. Under age 21 d. Under an age set by the state 4. Ethical codes provide ________ information counselors can use to inform their decision making. a. Clear b. General c. Legal d. Specific 5. With regard to counseling youth, competence requires: a. Taking a course in youth counseling b. Holding a master’s degree in counseling c. Obtaining supervised experience counseling youth d. Ongoing learning and practice counseling youth 6. A 16-year-old schedules a first session with a counselor and states she does not plan to tell her parents that she is coming to counseling. In this situation, the counselor should first: a. Refuse to meet with the youth without a parent present b. Obtain informed consent only from the 16-year-old c. Consult state laws regarding the age of consent d. Call the parent as soon as the session is over 7. A counselor is meeting with a 12-year-old client and his parents for the first time. In order to obtain informed consent, the counselor should do all of the following except: a. Provide a description of services, confidentiality, and legal requirements b. Describe the expectations for each family member regarding participation c. Describe the counselor’s credentials, training, experience, and background d. Obtain verbal and written consent from the 12-year old client 15 ..

8. The term that describes the legal protection of confidential information shared by a client is: a. Privacy b. Secrecy c. Confidentiality d. Privileged Communication 9. Generally speaking, confidentiality of minors is: a. Protected by federal law b. Not guaranteed by law c. Decided by the minor d. Decided by the parent 10. A counselor who is working with a minor counselor should: a. Inform the client of the legal limits of confidentiality for minors b. Inform the parents of all information shared in counseling c. Assure confidentiality to the minor in all circumstances d. Assure confidentiality to the minor except in cases of abuse or neglect 11. A major difference between confidentiality in school and mental health settings is that: a. Informed consent is difficult to obtain in school settings b. Informed consent does not apply in school settings c. Minors can provide informed consent in school settings d. Parents cannot provide informed consent in school settings 12. Among annual reports of child maltreatment, ________ involved cases of neglect. a. 55% b. 65% c. 75% d. 85% 13. With regard to reporting child abuse or neglect, counselors must: a. Adhere to state requirements for reporting b. Adhere to federal requirements for reporting c. Report all known abuse in all circumstances d. Report all suspected abuse in all circumstances 14. If a counselor feels uncomfortable with reporting child maltreatment, the counselor should: a. Avoid making the report b. Ask the client to make the report c. Ask the client’s parent to make the report d. Seek supervision and consultation

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15. When making a report of child abuse or neglect, the counselor should be prepared to provide all of the following except: a. Name of the child, parents, and perpetrator b. Client assessment history and diagnosis c. Addresses of the subjects of the report d. When and where the incident occurred 16. The law that protects confidential information maintained by organizations who transmit health care information electronically is called: a. HIPAA b. FERPA c. 42 CFR d. IDEA 17. The regulation that protects confidential information maintained by federally-funded substance use treatment facilities is called: a. HIPAA b. FERPA c. 42 CFR d. IDEA 18. The regulation that protects confidential information related to student educational records is called: a. HIPAA b. FERPA c. 42 CFR d. IDEA 19. The law that ensures youth with disabilities have access to a free public education that meets their unique learning needs is called: a. HIPAA b. FERPA c. 42 CFR d. IDEA 20. In cases of separation or divorce, counselors must obtain informed consent for counseling: a. The custodial parent only b. The custodial parent and step-parent, if applicable c. Both the custodial and non-custodial parents d. All individuals who have legal guardianship

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21. During the informed consent process, a counselor tells a family he has begun working with that he does not testify in court in cases of client custody. After six sessions, the counselor receives a court order requesting testimony in the couple’s custody case. In this situation the counselor should: a. Do nothing, as the informed consent document protects the counselor from testifying b. Do nothing, as the counselor does not have to testify due to legal privilege c. Consult with an attorney and provide the minimum amount of information required d. Consult with an attorney and provide all information contained in counseling records 22. A school counselor is called to testify regarding a custody case and, while on the stand, the counselor is asked to make a recommendation regarding custody. The counselor should: a. Refuse to provide a recommendation that is outside the counselor’s scope of practice b. Refuse to provide a recommendation without meeting with each parent first c. Provide an assessment of fitness of each parent and make a recommendation d. Provide information the client has shared regarding preferences for custody 23. An adolescent client who has been working on social skills invites his counselor to attend his opening baseball game of the season. In this situation, the counselor should: a. Refuse the invitation due to the unethical nature of multiple relationships b. Speak with the client and the counselor’s supervisor prior to making a decision c. Speak with the client’s parents and coach prior to making a decision d. Accept the invitation due to the progress the client has made in counseling 24. Unavoidable multiple relationships are most likely to occur in: a. Urban areas b. Suburban areas c. Rural areas d. Equally likely in all areas 25. Which of the following processes helps a counselor be thorough and thoughtful when resolving an ethical dilemma? a. Considering ethical principles and virtues b. Practicing within the counselor’s scope of practice c. Involving clients and guardians in decision making d. Engaging with professional counseling associations 26. Which of the following processes helps a counselor be educated when resolving an ethical dilemma? a. Considering ethical principles and virtues b. Practicing within the counselor’s scope of practice c. Involving clients and guardians in decision making d. Engaging with professional counseling associations 18 ..

27. Which of the following processes helps a counselor be sensitive and aware of self and others when resolving an ethical dilemma? a. Considering ethical principles and virtues b. Practicing within the counselor’s scope of practice c. Involving clients and guardians in decision making d. Engaging with professional counseling association 28. Which of the following processes helps a counselor be transparent and communicative when resolving an ethical dilemma? a. Considering ethical principles and virtues b. Practicing within the counselor’s scope of practice c. Involving clients and guardians in decision making d. Engaging with professional counseling associations 29. Ethical decision-making models involve all of the following processes except: a. Consulting professional counseling literature b. Reviewing professional ethical codes c. Avoiding consideration of bias or personal values d. Documenting outcomes of decision-making processes

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Chapter Five: Counseling Theories That Focus on Thought and Behavior Change and Action 1. A counselor uses theories to help: a. Know which diagnosis to assign b. Organize which information to collect c. Identify which billing codes to use d. Choose which medications to recommend 2. A(n) ________ is concrete and observable. a. Behavior b. Thought c. Emotion d. Interaction 3. Behavior therapy includes identification of target behaviors, which includes: a. New behaviors that will improve functioning b. New behaviors that will interfere with functioning c. Old behaviors that improve functioning d. Old behaviors that interfere with functioning 4. Behavior therapy requires that counselors are all of the following except: a. Structured b. Active c. Emotion-focused d. Learning-oriented 5. Behaviorists believe that behaviors are: a. A product of temperament b. A product of learning c. A product of emotions d. A product of cognitions 6. Within behavior therapy, ________ involves pairing a stimulus with a response to produce the desired response whenever the stimulus is presented. a. Classical conditioning b. Operant conditioning c. Instrumental conditioning d. Social learning 7. Within behavior therapy, ________ involves using reinforcements and consequences to influence behaviors. a. Classical conditioning b. Operant conditioning c. Respondent conditioning d. Social learning

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8. Within behavior therapy, ________ involves behavioral learning through observation. a. Classical conditioning b. Operant conditioning c. Instrumental conditioning d. Social learning 9. A child who develops anxiety due to being reprimanded every time she sits on the carpet is experiencing behavior change due to: a. Classical conditioning b. Operant conditioning c. Instrumental conditioning d. Social learning 10. A child who earns extra video game time if he completes his chores on time is experiencing behavior change due to: a. Classical conditioning b. Operant conditioning c. Respondent conditioning d. Social learning 11. A child who begins brushing her hair every morning after watching her mother brush her hair every morning is experiencing behavior change due to: a. Classical conditioning b. Operant conditioning c. Instrumental conditioning d. Social learning 12. A child whose parents ignore her tantrums are trying to change the child’s behavior through: a. Positive reinforcement b. Negative reinforcement c. Punishment d. Extinction 13. A child whose teacher allows him to skip the final math problem if he completes the first three successfully is trying to change the child’s behavior though: a. Positive reinforcement b. Negative reinforcement c. Punishment d. Extinction 14. In behavior therapy, the counselor’s primary task is to: a. Convey empathy and care to the client b. Explore client feelings and emotions c. Change client beliefs and cognitions d. Identify and change patterns of behavior

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15. The systematic procedure typically used in a behavioral therapy approach is called: a. Applied behavior analysis b. Functional behavioral assessment c. Functional analysis d. Behavioral shaping 16. A counselor using a behavioral approach would most likely ask which of the following questions during the assessment process? a. How do your thoughts impact your feelings? b. How do your feelings impact your thoughts? c. What happens before the problem occurs? d. What happens when you are feeling angry?

17. A child who acts out when her parents are spending time together watching a movie is most likely acting out to achieve: a. Attention b. Escape c. Sensation d. Reward 18. A child who acts out when he has difficulty completing his math homework is most likely acting out to achieve: a. Attention b. Escape c. Sensation d. Reward 19. In order to understand the function of behavior, counselors can study the ________ of the behavior. a. Rewards and consequences b. Antecedents and consequences c. Antecedents and punishments d. Rewards and punishments 20. A counselor using a behavioral approach encourages the parents to require the child to complete homework before having access to the computer. This counselor is encouraging the parents to use: a. Contingency management b. Classical conditioning c. Counterconditioning d. Psychoeducation 21. A counselor helps a client practice deep breathing techniques while imagining a high anxiety situation. This counselor is using the technique of: a. Contingency management b. Operant conditioning c. Counterconditioning d. Psychoeducation

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22. Social skills training is least likely to involve: a. Modeling b. Role playing c. Homework assignments d. Emotional exploration 23. A counselor who is using parent management training would likely do all of the following except: a. Teach conflict resolution skills b. Increase emotional congruence c. Coach parents on limit setting d. Describe age appropriate discipline 24. Which of the following is true about cognitive behavioral therapy? a. It is a unified model of counseling b. It focuses exclusively on thoughts and behaviors c. It encompasses a wide variety of approaches d. It has limited empirical support 25. A counselor using a CBT approach asks a client to challenge the belief that everyone talks about him when he isn’t around. The counselor is helping the client: a. Develop coping skills b. Enhance problem-solving skills c. Challenge faulty thinking patterns d. Promote positive decision-making 26. An underlying assumption of CBT is that: a. Emotions hold the capacity to influence behavior b. Cognitions can be monitored, assessed, and changed c. Behavior is a byproduct of learning patterns d. Behavior change can be achieved by changing emotions 27. The CBT model that presumes that all individuals are born with the innate capacity to think both rationally and irrationally is called: a. CT b. DBT c. MBI d. REBT 28. The CBT model that uses Socratic questioning and collaborative dialogue to help youth explore faulty cognitions and biased interpretations of events is called: a. CT b. DBT c. MBI d. REBT

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29. The CBT model that helps clients enhance inner awareness and nonjudgmental acceptance of both pleasure and distress is called: a. CT b. DBT c. MBI d. REBT 30. The CBT model that emphasizes emotional regulation and effective problem solving is called: a. CT b. DBT c. MBI d. REBT 31. A client who states “if I don’t get all As I will be a failure” is engaging in: a. Arbitrary inference b. Dichotomous thinking c. Selective abstractions d. Personalization 32. A client who states “I know they hate me because they were glaring while they were talking at the lunch table” is engaging in: a. Arbitrary inference b. Dichotomous thinking c. Selective abstractions d. Personalization 33. A client who states “I did a terrible job on my paper because I found a typo” is engaging in: a. Arbitrary inference b. Dichotomous thinking c. Selective abstractions d. Personalization 34. A client who states “my best friend didn’t answer her phone so I know she doesn’t want to be my friend anymore” is engaging in: a. Arbitrary inference b. Dichotomous thinking c. Selective abstractions d. Personalization 35. The cognitive triad includes all of the following except: a. Negative views about the world b. Negative views about others c. Negative views about oneself d. Negative views about the future

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36. The CBT-based approach that uses acronyms to promote coping and problem solving is: a. CT b. DBT c. MBI d. REBT 37. Reality therapy involves changing maladaptive behaviors to: a. Promote emotional congruence b. Experience more satisfying relationships c. Increase coping skills d. Improve communication patterns 38. The central foci of reality therapy are: a. Thoughts and emotions b. Choices and emotions c. Thoughts and behaviors d. Choices and behaviors 39. According to choice theory, the most important need humans have is: a. Fun b. Freedom c. Belonging d. Power 40. The belief that young people’s behaviors are directed toward resolving discrepancies between their quality world and their perceived world is a core tenet of: a. Cognitive therapy b. Reality therapy c. Dialectical behavior therapy d. Cognitive behavioral therapy 41. The belief that a strong therapeutic alliance is a requisite for client change is a foundation of: a. Cognitive therapy b. Reality therapy c. Rational emotive behavior therapy d. Cognitive behavioral therapy 42. A counselor who is using the WEDP system with a teenage client is using: a. Cognitive therapy b. Reality therapy c. Rational emotive behavior therapy d. Cognitive behavioral therapy

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Chapter Six: Counseling Theories That Focus on Background Experiences and Relationships 1. Psychodynamic theory is grounded in the idea that: a. Youth’s early life experiences are major influences personality and behavior b. Youth are constantly striving to become better versions of themselves c. Youth have a natural capacity to resolve their own problems d. Youth’s birth order influences their personality and behavior 2. The belief that transference-based thoughts, emotions, and behaviors are essential to the counseling process underlies: a. Adlerian therapy b. Individual psychology c. Person-centered therapy d. Psychodynamic therapy 3. The id, ego, and superego are elements of: a. Ego psychology b. Drive theory c. Object relations theory d. Attachment theory 4. Defense mechanisms are elements of: a. Ego psychology b. Drive theory c. Object relations theory d. Attachment theory 5. A child who punches a pillow when she is angry with her parents is engaging in: a. Reaction formation b. Projection c. Displacement d. Diversification 6. A child who is overly friendly to a peer who he dislikes is engaging in: a. Reaction formation b. Projection c. Displacement d. Diversification 7. A child who accuses her sibling of lying because she has been dishonest to her sibling is engaging in: a. Reaction formation b. Projection c. Displacement d. Diversification

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8. The psychosocial stage where youth are focused on developing control over their external worlds is: a. Autonomy vs. shame and doubt b. Initiative vs. guilt c. Industry vs. inferiority d. Identity vs. role confusion 9. The psychosocial stage that characterizes adolescence is: a. Autonomy vs. shame and doubt b. Initiative vs. guilt c. Industry vs. inferiority d. Identity vs. role confusion 10. In attachment theory, youth who experience ________ attachment typically have parents who are unresponsive to their physical or emotional needs. a. Ambivalent b. Avoidant c. Disorganized d. Secure 11. In attachment theory, youth who experience ________ attachment typically have parents who are inconsistent, may have unresolved trauma, and engage children in disorienting ways. a. Ambivalent b. Avoidant c. Disorganized d. Secure 12. The paradigm of ________ focuses on the development of healthy narcissism or sense of self. a. Attachment theory b. Ego psychology c. Self-psychology d. Separation-individuation theory 13. Goals of ________ include helping youth focus on expressing emotions, identifying recurrent themes and patterns, and enhancing self-understanding. a. Adlerian therapy b. Individual psychology c. Person-centered therapy d. Psychodynamic therapy 14. Transference and countertransference are elements of: a. Adlerian therapy b. Individual psychology c. Person-centered therapy d. Psychodynamic therapy

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15. A counselor asks a young person to draw a picture of a house, a person, and a tree during the assessment process. This counselor is most likely using: a. Adlerian therapy b. Individual psychology c. Person-centered therapy d. Psychodynamic therapy 16. A young person accidentally calls his counselor ‘Mom’ during a session. This is most likely a byproduct of: a. Transference b. Countertransference c. Defense mechanisms d. Resistance 17. Play, free association, and dream analysis are interventions likely to be used in: a. Adlerian therapy b. Individual psychology c. Person-centered therapy d. Psychodynamic therapy 18. The approach that views mental health difficulties as exaggerations of typical developmental processes is: a. Individual psychology b. Object relations theory c. Person-centered therapy d. Psychodynamic therapy 19. The approach that emphasizes the value of feelings of connectedness and contribution is: a. Individual psychology b. Object relations theory c. Person-centered therapy d. Psychodynamic therapy 20. In individual psychology, the term ________ describes a lingering sense of inequality that stems from an infant’s dependence on others. a. Felt minus b. Holism c. Inferiority complex d. Perceived plus 21. In individual psychology, the term ________ describes the integrated connection of all parts of an individual that is consistent and associated with their goals. a. Felt minus b. Holism c. Inferiority complex d. Perceived plus

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22. In individual psychology, the term ________ describes striving in one or two focused areas that is intended to overcome feelings of inferiority. a. Felt minus b. Holism c. Superiority complex d. Perceived plus 23. The counselor’s role in ________ is to encourage the client to thoughtfully explore his or her lifestyle. a. Individual psychology b. Object relations theory c. Person-centered therapy d. Psychodynamic therapy 24. A child who intentionally performs poorly on a baseball team so they won’t have to play baseball again is most likely driven by the mistaken goal of: a. Seeking attention b. Seeking power c. Seeking revenge d. Feelings of inadequacy 25. A child who breaks a sibling’s toy after the sibling tells on the child is most likely driven by the mistaken goal of: a. Seeking attention b. Seeking power c. Seeking revenge d. Feelings of inadequacy 26. A counselor who is conducting a lifestyle assessment will likely use all of the following processes except: a. Administering standardized tests b. Asking the client direct questions c. Observing the client’s behavior d. Interviewing people in the client’s life 27. When conducting a lifestyle assessment, the counselor might ask the child about memories from the first years of life to assess: a. Childhood attributes b. Early recollections c. Family constellation d. Hero identification 28. The counseling approach that emphasizes the counseling relationship as the necessary and essential vehicle for client change is: a. Individual psychology b. Object relations theory c. Person-centered therapy d. Psychodynamic therapy 29 ..

29. The counseling approach that values an egalitarian counselor-client relationship and aims to facilitate young clients’ natural growth processes is: a. Individual psychology b. Object relations theory c. Person-centered therapy d. Psychodynamic therapy 30. The counseling approach that believes clients are naturally predisposed to move away from maladjustment and move toward self-fulfillment is: a. Individual psychology b. Object relations theory c. Person-centered therapy d. Psychodynamic therapy 31. Youth who engage in constructive personal growth processes typically possess all of the following except: a. Openness to experience b. Trustworthy behavior c. Internal source of evaluation d. High level of self-confidence 32. A counselor who uses active listening, immediacy, and paraphrasing as primary counseling interventions is most likely using: a. Individual psychology b. Object relations theory c. Person-centered therapy d. Psychodynamic therapy

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Chapter Seven: Counseling Theories That Focus on Family Change Processes 1. Family therapy differs from individual counseling in that it involves: a. Diagnosing all family members b. Meeting only adults in a family c. Focusing on systemic interactions d. Avoiding the use of assessment 2. Family therapy views young people’s behaviors as rooted in: a. Early childhood experiences b. Interactions among the family c. Feelings of inferiority d. Inherited biological traits 3. Within systems theory, a family’s interactional processes demonstrate a pattern known as: a. Linear causality b. Circular causality c. Diagonal causality d. Dynamic causality 4. A family where an adolescent asks his parents to make major decisions for him most likely has: a. Healthy boundaries b. Enmeshed boundaries c. Disengaged boundaries d. Subsystem boundaries 5. A counselor who is using family therapy is likely to use each of the following approaches except: a. Creating a non-directive environment b. Teaching families about communication c. Coaching family members in interactions d. Advocating for each family member’s needs 6. The process of ________ is essential in the initial stages of family counseling: a. Challenging b. Encouraging c. Joining d. Aligning 7. Change in family counseling is demonstrated through: a. Increased insight b. Self-actualization c. Behavior change d. Emotional catharsis

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8. A genogram is used to explore family: a. Dynamics b. Hierarchies c. Structure d. Subsystems 9. With regard to individual and family counseling, counselors working with youth are best served by: a. Providing family or individual counseling exclusively b. Beginning with individual counseling and following with family counseling c. Beginning with family counseling and following with individual counseling d. Blending individual and family counseling as necessary 10. Focusing on ________ tends to be the first course of action in most family-focused counseling approaches. a. Boundaries b. Communication c. Hierarchies d. Subsystems 11. Circular questioning is a technique that family counselors can use to: a. Facilitate communication b. Promote Insight c. Reframe challenges and difficulties d. Address disengagement and enmeshment 12. Helping families manage intense emotions is a process family counselors can use to: a. Facilitate communication b. Promote Insight c. Reframe challenges and difficulties d. Address disengagement and enmeshment 13. Helping families develop more realistic interpretations of events can be used to: a. Facilitate communication b. Promote Insight c. Reframe challenges and difficulties d. Address disengagement and enmeshment 14. All of the following processes help counselors reframe challenges and difficulties except: a. Validating perspectives b. Providing an alternative c. Offering interpretations d. Assessing for agreement

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15. The term that describes an individual’s ability to separate intellectual and emotional functioning from that of family members is: a. Enmeshment b. Disengagement c. Differentiation d. Fusion 16. The term that describes an individual’s inability to separate thoughts and feelings from those of family members is: a. Enmeshment b. Disengagement c. Differentiation d. Fusion 17. The term that describes inappropriate, boundary-violating closeness in a family is: a. Enmeshment b. Disengagement c. Differentiation d. Fusion 18. A counselor working with a family finds that each week, the family fails to follow through on homework assignments. The family is likely striving to maintain: a. Boundaries b. Disengagement c. Enmeshment d. Homeostasis 19. A(n) ________ is a way of interacting that promotes movement away from homeostasis. a. Negative feedback loop b. Positive feedback loop c. Paradoxical injunction d. Indirect directive 20. A(n) ________ a command from the counselor that appears to be opposed to the goals of counseling, such as “prescribing the problem”. a. Negative feedback loop b. Positive feedback loop c. Paradoxical injunction d. Indirect directive

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Chapter Eight: The Use of Play and Creative Arts in Counseling 1. In which of the following situation is a counselor most likely to use play to help a client? a. An adolescent is having academic difficulties due to a learning disability b. A 10-year-old is having difficulty expressing his emotions about his grandmother’s death c. An adolescent is experiencing symptoms of major depression, including suicidal ideation d. A 10-year-old is experiencing symptoms of bipolar disorder, including mania 2. A counselor may call him or herself a play therapist if he or she: a. Uses play regularly in counseling b. Completed a course in play therapy c. Holds play therapy licensure d. Obtained play therapy certification 3. All of the following terms may be used by licensed mental health counselors with generalist training except: a. Art therapy b. Creative arts therapy c. Expressive therapy d. Expressive arts therapy 4. Play therapy is a counseling approach where the counselor: a. Uses manualized treatment to help the child interact with play materials b. Uses naturally occurring playful behaviors of youth to facilitate change c. Uses standardized interventions to promote prosocial play behaviors in youth d. Uses play a reward for prosocial behaviors and choices during sessions 5. With regard to play therapy in schools, play therapy is: a. Not appropriate for school settings b. Appropriate only for young children c. Something to be used with caution d. Well-suited for school-based interventions 6. When using toys in play therapy, the counselor should: a. Provide the child with access to all available toys b. Select the specific toys the child will play with c. Offer toys that align with dominant cultural norms d. Use only toys that are new and realistic-looking 7. Play was first used as a therapeutic intervention within the realm of: a. Cognitive-behavioral therapy b. Person-centered therapy c. Psychoanalytic therapy d. Reality therapy

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8. With regard to emotional expression in play therapy, youth typically: a. Initially express unpleasant emotions b. Initially have limited emotional expression c. Develop positive emotions over time d. Develop emotional processing skills over time 9. A counselor is working with a young child who regularly experiences conflict with her mother. In this situation, the best way to involve her mother would be to: a. Meet with the mother separately at the end of session to debrief b. Meet with the mother separately before the session to check in c. Have the mother quietly observe the play therapy sessions d. Have the mother actively participate in the play therapy sessions 10. When using play therapy, a counselor should plan for a session that: a. Lasts no longer than 30 minutes b. Lasts approximately 50 minutes c. Lasts as long as is developmentally appropriate d. Lasts as long as is allotted by insurance regulations 11. Cleaning up after a play therapy session: a. Should be done by the client in all cases b. Should be done by the counselor in all cases c. Should be done based on goals of counseling d. Should be done based on how materials are stored 12. Which of the following is a form of directive play therapy? a. Theraplay b. Child-centered play therapy c. Filial therapy d. Experiential play therapy 13. Which of the following is a form of non-directive play therapy? a. Theraplay b. Filial therapy c. Release play therapy d. Adlerian play therapy 14. A counselor uses play therapy with a young person to support progression through five stages of play therapy. This counselor is most likely using: a. Theraplay b. Child-centered play therapy c. Filial therapy d. Experiential play therapy 15. A counselor uses play therapy with a young person while her family is present and actively encouraged to participate. This counselor is most likely using: a. Adlerian play therapy b. Child-centered play therapy c. Filial therapy 35 ..

d. Experiential play therapy 16. A counselor using play therapy intentionally creates play situations that are metaphors for the youth’s current difficulties and experiences. This counselor is most likely using: a. Child-centered play therapy b. Filial therapy c. Release play therapy d. Adlerian play therapy 17. The form of play therapy that is a directive process used to foster healthy attachment between youth and caregiver is called: a. Theraplay b. Filial therapy c. Release play therapy d. Adlerian play therapy 18. In experiential play therapy, the process where the child is determining whether the counselor can be trusted is called the ________ stage. a. Exploratory b. Testing c. Dependency d. Therapeutic growth 19. In experiential play therapy, the stage where the client becomes willing to share difficult thoughts and feelings through play is called the ________ stage. a. Exploratory b. Testing c. Dependency d. Therapeutic growth 20. When using sandplay, counselors encourage clients to: a. Place small objects in the sand b. Build structures with the sand c. Write words in the sand d. Practice mindfulness techniques with sand 21. Using art in counseling is especially relevant with clients who have: a. Strong verbal expression b. Limited verbal expression c. Strong artistic ability d. Limited artistic ability 22. The term ________ refers to a theoretical foundation that encourages youth to enact important life events that still feel unfinished. a. Psychodrama b. Narrative therapy c. Therapeutic storytelling d. Music therapy

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Chapter Nine: Conceptualizing Young Clients’ Situations and Directing Counseling 1. The therapeutic alliance is: a. Important primarily in individual counseling b. Important primarily in family counseling c. The most important predictor of successful counseling d. The least important predictor of successful counseling 2. When developing a treatment plan, it is important to: a. Use standardized goals and objectives for all clients b. Limit the input the client’s family has on the process c. Involve the young person in the process d. Select goals and objectives mandated by insurance payers 3. Focusing on evidence-based practice means that a counselor: a. Conducts research on his or her clinical practice b. Uses research to select effective interventions c. Selects interventions that the counselor has experience with d. Reports outcome data on interventions to researchers 4. Considering cultural factors in treatment planning is important because: a. Clients must learn to assimilate to the dominant culture b. Counseling values are most congruent with marginalized cultures c. Clients make meaning of problems within the context of culture d. Counseling goals need to reflect the norms of the dominant culture 5. Following the Golden Thread involves first: a. Assigning a diagnosis b. Identifying client goals c. Developing treatment objectives d. Providing therapeutic interventions 6. A counselor working with a young client on social skills learns that the client has recently lost a beloved pet. In the situation, the best course of action is to: a. Continue providing interventions focused on social skills to adhere to the treatment plan b. Deviate from the treatment plan to address feelings of grief and loss c. Amend the treatment plan to include addressing grief and loss as treatment goals d. Refer the client to a grief counselor to help the client process the loss 7. Within the I CAN START model, the I stands for: a. Independent b. Individual c. Interests d. Involvement

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8. Which of the following would be most appropriate for the I element of the I CAN START model? a. Assessing client functioning b. Administering standardized tests c. Reflecting on personal values d. Exploring family dynamics 9. Countertransference occurs when: a. A client projects his or her feelings toward another person onto the counselor b. A counselor projects his or her feelings toward another person onto the client c. A parent projects his or her feelings toward another person onto the client d. A client projects his or her feelings toward another person onto the parent 10. Within the I CAN START model, the C stands for: a. Causes and effects b. Contributions of family c. Contextual assessment d. Cultural factors 11. Which of the following would be most appropriate for the C element of the I CAN START model? a. Identifying client strengths b. Exploring client development c. Collecting academic progress data d. Assigning a diagnosis 12. In ecological systems theory, the ________ describes the overarching beliefs and values of a culture or society. a. Microsystem b. Mesosystem c. Exosystem d. Macrosystem 13. Within the I CAN START model, the first A stands for: a. Assessment and diagnosis b. Application and decision-making c. Application and diagnosis d. Assessment and decision-making 14. Which of the following would be most appropriate for the first A element of the I CAN START model? a. Exploring client development b. Administering formal assessments c. Reflecting on personal values d. Examining contextual factors

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15. A counselor conducting a mental status examination would assess all of the following except: a. Appearance b. Behaviors c. Judgement d. Suicidality 16. Within the I CAN START model, the N stands for: a. Necessary level of care b. Needed interventions c. Notable strengths d. Negative consequences 17. Which of the following would be most appropriate for the N element of the I CAN START model? a. Assessing client values b. Administering standardized tests c. Exploring symptom severity d. Identifying personal biases 18. Within the I CAN START model, the S stands for: a. Strategies b. Strengths c. Structure d. Support 19. Which of the following would be most appropriate for the S element of the I CAN START model? a. Assessing client development b. Administering standardized assessments c. Exploring client strengths d. Identifying strategies for intervention 20. Within the I CAN START model, the first T stands for: a. Theories b. Techniques c. Treatment approach d. Technical specifications 21. Which of the following would be most appropriate for the first T element of the I CAN START model? a. Documenting client outcomes b. Administering standardized tests c. Selecting a theoretical approach d. Exploring family dynamics

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22. Within the I CAN START model, the second A stands for: a. Aims and objectives b. Aims and treatments c. Assessment and objectives d. Assessment and treatment 23. Which of the following would be most appropriate for the second A element of the I CAN START model? a. Developing treatment goals b. Documenting client outcomes c. Assigning a diagnosis d. Measuring treatment progress 24. The SMART model is used to: a. Determine an appropriate diagnosis b. Assess client functioning c. Select evidence-based practices d. Develop treatment objectives 25. Within the I CAN START model, the R stands for: a. Responsive interventions b. Research-based interventions c. Required interventions d. Recommended interventions 26. Which of the following would be most appropriate for the R element of the I CAN START model? a. Developing treatment goals b. Documenting client outcomes c. Selecting appropriate interventions d. Assessing family engagement 27. Within the I CAN START model, the second T stands for: a. Techniques and processes b. Treatment outcomes c. Therapeutic support services d. Time-limited objectives 28. Which of the following would be most appropriate for the second T element of the I CAN START model? a. Developing treatment goals b. Documenting client outcomes c. Assigning a diagnosis d. Referring a client to a support group

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Chapter Ten: Youth Suicide, Self-Injury, and Homicide 1. Suicide is the ________ leading cause of death of adolescents. a. First b. Second c. Third d. Fourth 2. A natural initial reaction of counselors working with young clients who have suicidal ideation is to feel ________. a. Angry b. Anxious c. Frustrated d. Overconfident 3. Ethical and legal considerations for counselors working with suicidal clients include all of the following except: a. Ensuring concrete measures are taken to promote safety b. Documenting steps taken to enhance client safety c. Knowing state guidelines related to hospitalization of minors d. Avoiding breaking confidentiality and not informing parents of client suicidality 4. In terms of risk factors related to suicide, ________ are more likely to use violent means in attempting suicide. a. Adolescent boys b. Adolescent girls c. Pre-adolescent boys d. Pre-adolescent girls 5. The racial/ethnic group most at risk for suicide or suicide attempts is: a. African Americans b. American Indian/Alaskan Natives c. Asian Americans d. Caucasians 6. All of the following factors have been identified as potential indicators of suicidality except: a. Substance abuse problems b. Sexual orientation or gender identity struggles c. The presence of a mental health disorder d. High academic expectations 7. Potential suicide risk should be assessed: a. During every session for all clients b. During the intake session for all clients c. Only after getting to know the client d. Only when risk factors are present

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8. A counselor is using the mnemonic SAD PERSONS to conduct an assessment. The counselor is most likely assessing: a. Mental status b. Suicide risk c. Self-injury risk d. Homicide risk 9. Commitment to Counseling statements can be used: a. To help clients cope with difficult emotions and stressors b. To protect the counselor from legal liability related to suicide c. To create a contract prohibiting the client from attempting suicide d. To alert parents to a young person’s suicide risk and ideation 10. Safety plans should be: a. Created with the client during a session b. Standardized for use with all clients c. Used only in cases with high risk of suicide d. Avoided due to legal risks 11. A school counselor is developing a school-based suicide intervention program. The program is likely to be most effective if the school counselor: a. Focuses on one grade level b. Begins in the early grades c. Involves parents in programming d. Prioritizes character development 12. Which of the following is true about nonsuicidal self-injury? a. Most nonsuicidal self-injury is unintentional b. Nonsuicidal self-injury involves piercing and tattoos c. The typical onset of nonsuicidal self-injury occurs between 12 and 14 d. Nonsuicidal self-injury is listed in the anxiety disorders section of the DSM-5 13. Individuals with nonsuicidal self-injury have a(n) ________ risk of suicide attempts. a. Increased b. Decreased c. Slight d. High 14. A counselor’s assessment of non-suicidal self-injury typically includes all of the following except: a. Exploring triggers b. Identifying age of onset c. Providing medical care d. Assessing substance use

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15. Interventions for nonsuicidal self-injury typically involve the use of: a. Psychodynamic therapy b. Person-centered therapy c. Reality therapy d. Cognitive-behavioral therapy 16. An approach that can help clients resolve ambivalence around changing nonsuicidal self-injury patterns is: a. Cognitive-behavioral therapy b. Motivational interviewing c. Dialectical-behavioral therapy d. Problem-solving therapy 17. Approximately ________ percent of student in grades 9-12 reported carrying a weapon more than 1 day in the previous 30 days prior to being surveyed. a. 8% b. 16% c. 24% d. 32% 18. In terms of school based homicide prevention, ________ prevention strategies focus on actions that take place immediately following a crisis to minimize traumatization. a. Primary b. Secondary c. Tertiary d. Universal 19. The personality traits of violent offenders typically include: a. Intense and unstable peer relationships b. Avoidance of social interactions c. Disregard for social norms d. Excessive need for attention 20. When assessing for homicidal risk, counselors should: a. Begin by speaking with the client’s parents b. Initiate the conversation in a subtle way c. Ensure the assessment occurs in a safe environment d. Avoid using the word ‘homicide’ during the assessment 21. A counselor is using the mnemonic SIMPLE STEPS to conduct an assessment. The counselor is most likely assessing: a. Mental status b. Suicide risk c. Self-injury risk d. Homicide risk

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22. If a counselor determines a client is a danger to others, the counselor should do all of the following except: a. Contact the client’s parents b. Recommend pharmaceutical interventions c. Consult ethical codes and legal requirements d. Recommend referral to a higher level of care

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Chapter Eleven: Family-Related Transitions and Struggles 1. Which of the following represents a family-structure transition? a. A mother is abusing alcohol b. A child’s pet dog has died c. A father remarries after divorce d. A child experiences physical abuse 2. A child who reacts to divorce by trying to rescue the marriage is most likely in the ________ stage of development. a. Infancy b. Early childhood c. Middle childhood d. Adolescence 3. Exposure to ________ is the single biggest predictor of negative outcomes for children and adolescents making the transition through divorce. a. Parental infidelity b. Marital conflict c. Parental relocation d. Marital financial challenges 4. Protective factors that help to diminish internalizing consequences of divorce include all of the following except: a. Higher family income b. Consistent parenting c. Higher IQ d. Parental remarriage 5. Stepfamilies are different from first-time families because: a. There is often a new legal relationship between child and step-parent b. The parent-child relationship has existed longer than the couple relationship c. Children typically maintain a relationship with only one parent d. Step-parents are less likely to serve in an adult parental role 6. The PRIDE acronym is most useful when working with families impacted by: a. Remarriage b. Grief and loss c. Substance abuse d. Physical abuse 7. A client is working with a young child who is residing with her maternal grandmother while the mother is incarcerated. The grandmother would best be described as a(n): a. Step-parent b. Adoptive parent c. Kinship caregiver d. Foster caregiver

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8. When working with youth who reside with an adult other than the biological parents, the most important factor to consider regarding guardianship prior to initiating services is whether: a. The child resides in the adult’s household b. The child is related to the adult c. The adult has completed the informed consent process d. The adult has legal custody of the child 9. On average, ________ young people are adopted each year in the United States. a. 60,000 b. 120,000 c. 180,000 d. 240,000 10. A young child who was adopted from the foster care system whose adoptive family knows nothing about her biological parents was likely adopted through the process of a(n) ________ adoption. a. Closed domestic b. Closed international c. Open domestic d. Open international 11. Which of the following is true regarding families involved in the adoption process? a. Most families do not need counseling b. Most families do need counseling c. Most families fail to adapt d. Most families easily adapt 12. The adolescent process of ________ can be impacted by adoption in childhood. a. Attachment b. Repair c. Identity formation d. Ego development 13. The disorder formerly known as fetal alcohol syndrome is now called: a. Alcohol-induced neurodevelopmental disorder b. Alcohol-related neurodevelopmental disorder c. Alcohol-induced psychomotor disorder d. Alcohol-related psychomotor disorder 14. When working with a family impacted by substance use, the first thing the counselor should do is: a. Assess the severity of the substance use disorder b. Assess the symptoms of other mental health symptoms c. Assess the immediate safety of family members d. Assess the risk of withdrawal symptoms

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15. With regard to substance use disorders in a family, the three C’s refer to: a. Cause, care, concern b. Cause, control, cure c. Consequences, control, care d. Consequences, concern, cure 16. A young person who berates her parents for letting her dog die is most likely experiencing the ________ stage of grief. a. Denial b. Anger c. Bargaining d. Sorrow 17. A young person who describes seeing his deceased grandparent in the hallway at night is most likely experiencing the ________ stage of grief. a. Denial b. Anger c. Bargaining d. Sorrow 18. With regard to conceptualizing death, youth in the ________ stage equate death with sleep. a. Infancy b. Early childhood c. Middle childhood d. Adolescence 19. Which of the following is the most likely indicator of childhood traumatic grief? a. Increased conflict with siblings b. Increased tearfulness c. Reports of headaches d. Reports of intrusive thoughts 20. The most effective approach for treating grief and loss in youth is: a. Adlerian therapy b. Behavioral therapy c. Cognitive behavioral therapy d. Psychodynamic therapy

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Chapter Twelve: Academic and Social/Emotional Transitions and Struggles 1. Academic achievement in youth is: a. Defined as scoring above the mean on standardized tests b. Valued consistently across cultures c. Connected with increased sense of purpose in youth d. Primarily the domain of mental health counselors 2. Youth who procrastinate tend to: a. View willpower as an unlimited resource b. Fail to consider short-term rewards c. Struggle with effective time management d. Perform comparably to their peers academically 3. Signs of time management difficulties in youth who have high aptitude yet are not performing well in the classroom include all of the following except: a. Inadequate short-term memory b. Limited executive processing abilities c. Difficulty with self-control d. A tendency to procrastinate 4. A young person who is experiencing time management difficulties should be assessed for ________ as a differential diagnosis. a. Conduct disorder b. Depressive disorder c. Specific phobia d. Rumination disorder 5. A counselor working with a child who struggles with time management would be most likely to use a(n): a. Art-based intervention b. Cognitive intervention c. Psychodynamic intervention d. Family-based intervention 6. Youth age 6-13 years need approximately ________ hours of sleep a night. a. 8-10 b. 9-11 c. 10-18 d. 11-13 7. Study skills are influenced by: a. Teacher effectiveness b. Student interest c. Developmental level d. Classroom management

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8. Study skills are usually taught by: a. Counselors b. Parents c. Siblings d. Teachers 9. A school counselor is working with an elementary school student on improving study skills. The first step the counselor should take is to: a. Explore reading comprehension b. Address differential diagnoses c. Teach key note-taking concepts d. Refer the youth to a tutor 10. A counselor using a parent training approach to time-management difficulties would most likely focus on which of the following counseling goals? a. Increase youth academic self-efficacy b. Identify triggers for emotional distress c. Establish routine and structure d. Use healthy coping skills 11. Test anxiety is best described as: a. A diagnosable mental health disorder b. A typical developmental milestone c. Generally mild in terms of symptoms d. Associated with physical and psychological symptoms 12. School refusal is typically a result of: a. Fear of academic struggles b. Difficulty following school rules c. Conduct disorder d. Delinquent behaviors 13. Truancy is typically a result of: a. Separation anxiety b. Depression c. Social phobia d. Conduct disorder 14. Normative school transitions include changing schools due to: a. Parental relocation b. Changing grades c. Parental divorce d. Custody change 15. A challenge unique to non-normative school transitions is: a. Uncertainty of the new school culture b. Worries about school rules c. Unfamiliarity with building layout d. Feelings of isolation 49 ..

16. Friendships typically develop between youth who: a. Have varied interests b. Share similar struggles c. Are ethnically diverse d. Are a different gender 17. Emotions that underlie bullying may include all of the following except: a. Anxiety b. Fear c. Overconfidence d. Sadness 18. Youth who have mental health difficulties are at increased risk of becoming: a. Bullies b. Bully-victims c. Bystanders d. Victims 19. Harmful side effects of bullying including depression, low self-esteem, and suicide, are likely to affect: a. Bullies b. Bystanders c. Victims d. All parties involved 20. An appropriate counseling goal for working with bullies includes: a. Increasing self-defense strategies b. Increasing connections with allies c. Holding youth accountable d. Teaching methods for seeking support 21. An appropriate counseling goal for working with bystanders includes: a. Increasing self-defense strategies b. Increasing connections with allies c. Holding youth accountable d. Teaching methods for seeking support 22. Sexual orientation begins to develop in: a. Infancy b. Early childhood c. Early adolescence d. Late adolescence 23. The term that describes an individual who provides support to others who are LGBTQ is: a. Ally b. Intersex c. Queer d. Questioning

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25. The term that describes an individual born with both male and female sex organs is: a. Intersex b. Queer c. Questioning d. Transgender 26. Struggles typically associated with LGBTQ status include all of the following except: a. Anxiety b. Bipolar disorder c. Depression d. Homelessness 27. When working with LGBTQ youth, counselors should ________ the difficulties experienced by youth. a. Eliminate b. Emphasize c. Minimize d. Validate 28. An adolescent experiencing romantic difficulties is at a higher risk of: a. Academic difficulties b. ADHD c. Bipolar disorder d. Social rejection 29. Male youth who experience intimate partner violence in the home are ________ to reproduce this behavior in their own relationships. a. Guaranteed b. More likely c. Less likely d. Unlikely

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Chapter Thirteen: Neurodevelopmental and Intellectual Impairments 1. The term that describes basic skills needed to handle and meet the needs of everyday life is: a. Adaptive functioning b. Adequate functioning c. Adaptive coping d. Adequate coping 2. All intellectual and neurodevelopmental disorders share: a. Symptoms of social skills deficits b. Symptoms of gross motor deficits c. Disruption of brain-related development d. Disruption of socio-emotional development 3. Based on a counselor’s observation of a child who fidgets with her pencil and struggles to sit quietly during class, the most likely diagnosis the counselor would assign is: a. ADHD, predominantly inattentive type b. ADHD, predominantly hyperactive/impulsive type c. ADHD, combined type d. ADHD, unspecified type 4. The onset of symptoms of ADHD traditionally occurs before age: a. 5 b. 7 c. 9 d. 11 5. Youth with ADHD benefit from counseling interventions that: a. Are loosely structured b. Are multidisciplined c. Require hyperfocus d. Require physical movement 6. Parents’ lower recognition of ADHD symptoms as problematic may be attributed to all of the following except: a. Lower recognition of symptoms as problematic b. Parental concern regarding impact of diagnosis c. Feeling mistrustful of surrounding systems d. Low parent-child cohesion in the family 7. Counseling interventions for ADHD are most likely to be effective when they: a. Target school-based problems b. Address home-based problems c. Involve parents and teachers d. Focus on academic difficulties

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8. The most empirically-supported counseling intervention for ADHD is: a. Cognitive-behavioral therapy b. Expressive arts therapy c. Person-centered therapy d. Play therapy 9. With regard to psychopharmacotherapy, ________ medications can be effective in reducing symptoms in youth who have ADHD. a. Antidepressants b. Antipsychotics c. Mood stabilizers d. Stimulants 10. A risk factor for autism spectrum disorder includes: a. Young maternal age b. Young paternal age c. Pollutant exposure d. Childhood vaccinations 11. The term that describes the behavior of repeating what is heard is: a. Repetitive speech b. Echolalia c. Self-stimulatory speech d. Stereotypical speech 12. The hallmark symptom of autism spectrum disorder is: a. Above-average intelligence b. Below-average intelligence c. Communication skills deficits d. Excessive motor activity 13. Intervention for autism spectrum disorder is most likely to optimize long term functioning when it occurs: a. During early childhood b. During elementary school c. During middle school d. During high school 14. Family involvement in treatment for autism spectrum disorder is: a. Generally considered unnecessary b. Beneficial only with mild symptoms c. Necessary for effective treatment d. Incompatible with behavioral interventions 15. Assessments for autism spectrum disorders are typically: a. Based on standardized test scores b. Conducted upon entering school c. Incomplete without collateral reports d. Effective in early childhood

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16. ABA is the most effective form of therapy for autism spectrum disorder. ABA stands for: a. Appropriate Behavior Application b. Appropriate Behavior Analysis c. Applied Behavior Application d. Applied Behavior Analysis 17. A common factor among all youth who have intellectual disabilities is an IQ score below: a. 90 b. 80 c. 70 d. 60 18. Assessment of ________ helps counselors determine the degree of impairment of youth with an intellectual disability. a. Adaptive functioning b. Adequate functioning c. Adaptive coping d. Adequate coping 19. The use of standardized assessments to diagnose an intellectual disability are: a. Avoided b. Discouraged c. Recommended d. Required 20. One of the most essential counseling components when working with youth with an intellectual disability is: a. Applied behavior analysis b. Case management c. Cognitive-behavioral therapy d. Parent training 21. Specific learning disorders affect ________ percent of school-age children. a. 2-5 b. 5-15 c. 15-25 d. 25-30 22. Specific learning disorders are least likely to impact: a. Reading comprehension b. Reading fluency c. Mathematical reasoning d. Scientific reasoning

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23. Learning disorders are typically addressed through: a. An individualized education program b. Cognitive-behavioral therapy c. Contingency management d. Solution-focused therapy

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Chapter Fourteen: Disruptive Behavior Problems 1. The prognosis for behavior problems can be good, especially if: a. The behavior started in early childhood b. The behavior started in adolescence c. Counseling is begun early d. Counseling is initiated by the youth 2. Behavior problems are diagnosed in cases where the behaviors: a. Occur in response to frustration or tiredness b. Are a byproduct of another mental health disorder c. Reflect behavioral regression d. Cause significant impairment 3. Disorders included in the DSM-5 category include all of the following except: a. Intermittent explosive disorder b. Kleptomania c. Pyromania d. Trichotillomania 4. One factor that may contribute to disruptive behavior problems in youth is: a. Secure parental attachment b. Parental mental health concerns c. Higher frustration tolerance d. Higher IQ 5. A child who regularly uses illegal substances is demonstrating disruptive behavior in the area of: a. Stubborn behavior b. Defiance/disobedience c. Authority problems d. Minor aggression 6. A child who vandalizes a neighbor’s fence is demonstrating disruptive behavior in the area of: a. Minor covert acts b. Property damage c. Moderate to serious delinquency d. Physical aggression 7. A child who engages in nonsuicidal self-injurious behavior is demonstrating disruptive behavior in the area of: a. Minor aggression b. Physical aggression c. Severe violence d. Authority problems

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8. A child who has stolen from teachers in school, regularly smokes marijuana, and has threatened to kill her parents is most likely to be diagnosed with: a. Oppositional defiant disorder b. Conduct disorder c. Intermittent explosive disorder d. Kleptomania 9. Which of the following should be considered as a potential differential diagnosis when considering diagnosing a youth with a disruptive behavioral disorder a. Specific learning disorder b. Obsessive-compulsive disorder c. Neurodevelopmental disorder d. Rumination disorder 10. When conducting an assessment for a disruptive behavioral disorder, standardized assessments: a. Have limited use in youth b. May include a survey for parents c. Are sufficient for determining a diagnosis d. Are often unreliable in youth 11. Counseling for disruptive behavioral disorders is most effective when: a. Conducted in an individual setting b. Provided in a group setting c. Family members are involved d. Facilitated by school counselors 12. A counselor would most likely use ________ to help a child become aware of her inner workings and support healthy behaviors. a. Behavioral therapy b. Mindfulness-based skills c. Problem-solving skills d. Parent management training 13. Beck’s cognitive triad is a(n): a. Mindfulness-based breathing technique b. Technique for tracking thoughts, feelings, and behaviors c. Technique for integrating emotional and cognitive processes d. Family-based intervention to promote communication 14. Problem-solving skills training rests on the assumption that ________ is/are at the heart of disruptive behaviors. a. Lack of emotional awareness b. Poor social skills c. Ineffective cognitions d. Low family cohesion

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16. When applying problem-solving skills training, the first question youth should ask themselves is: a. What choice should I make? b. What will happen if I do this? c. What else can I do? d. What am I supposed to do?

17. When applying problem-solving skills training, the last question youth should ask themselves is: a. What choice should I make? b. What will happen if I do this? c. How did I do? d. What am I supposed to do?

18. PSST is especially relevant in: a. Residential treatment settings b. School-based settings c. Outpatient settings d. In-home counseling setting 19. A youth who is participating in a DBT group to manage disruptive behaviors is most likely working to: a. Replace ineffective behaviors with effective behaviors b. Identify and change faulty cognitions c. Effectively regulate his or her emotions d. Develop insight regarding family dynamics 20. A counselor who uses multisystemic therapy to treat disruptive behavior problems will combine elements of all of the following except: a. Cognitive-behavioral therapy b. Person-centered therapy c. Family therapy d. Community psychology foundations 21. Multisystemic therapy typically takes place in: a. The child’s school b. Outpatient counseling settings c. The family’s home d. Residential counseling settings 22. Medication is ________ to address symptoms of disruptive behavior problems. a. Typically necessary b. Strongly encouraged c. Not commonly supported d. Not effective

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Chapter Fifteen: Abuse and Trauma 1. Which of the following is considered a type I traumatic event? a. Domestic violence b. Child abuse c. Child neglect d. A school shooting 2. Which of the following is considered a type 2 traumatic event: a. Hurricane b. Car accident c. Robbery d. Bullying 3. With regard to traumatic experience, it is expected that: a. All youth will require counseling after experiencing trauma b. Trauma symptoms are similar in youth regardless of experience c. Traumatic experiences generally warrant a clinical diagnosis d. Youth who experience type 2 trauma generally have a poorer prognosis 4. If violence is a component of a traumatic event, youth have an increased risk of all of the following except: a. Conduct difficulties b. Learning disorders c. Substance use disorders d. Repeated victimization 5. In terms of child maltreatment, ________ is the most pervasive type of maltreatment. a. Neglect b. Physical abuse c. Emotional abuse d. Sexual abuse 6. Youth who are victims of maltreatment who have noticeable bruises or scars after an absence from school are most likely to have experienced: a. Neglect b. Physical abuse c. Emotional abuse d. Sexual abuse 7. Parents who are perpetrators of maltreatment who display aggression toward a child in social situations are most likely to be perpetrators of: a. Neglect b. Physical abuse c. Emotional abuse d. Sexual abuse

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9. Youth who have experienced maltreatment who attach quickly to unknown adults are most likely to have experienced: a. Neglect b. Physical abuse c. Emotional abuse d. Sexual abuse 10. Parents who are perpetrators of maltreatment who isolate youth from interactions with other adults are most likely to be perpetrators of: a. Neglect b. Physical abuse c. Emotional abuse d. Sexual abuse 11. Youth who are victims of maltreatment who demonstrate indifference and lack of attachment to parents are most likely to have experienced: a. Neglect b. Physical abuse c. Emotional abuse d. Sexual abuse 12. Parents who are perpetrators of maltreatment who frequently blame or belittle the child in front of others are most likely to be perpetrators of: a. Neglect b. Physical abuse c. Emotional abuse d. Sexual abuse 13. Youth who are victims of maltreatment who demonstrate hygiene issues such as body odor and bad breath are most likely to have experienced: a. Neglect b. Physical abuse c. Emotional abuse d. Sexual abuse 14. Parents who are perpetrators of maltreatment who have a severe substance use or mental health disorder are most likely to be perpetrators of: a. Neglect b. Physical abuse c. Emotional abuse d. Sexual abuse 15. A child reports his parents have encouraged him to drink alcohol and smoke marijuana with them. This is best described as: a. Rejecting b. Intimidating c. Isolating d. Corrupting

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17. A counselor learns that an eight-year-old child is regularly left to care for her infant sibling while their mother is at work. This is best described as: a. Physical neglect b. Emotional neglect c. Medical neglect d. Educational neglect 18. Young children who witness intimate partner violence: a. Often willingly describe their experiences in counseling b. Are typically minimally impacted by the experience c. May also become victims of IPV themselves d. Very often become perpetrators of violence 19. Youth who are exposed to natural disasters through the media: a. Are typically unaffected by the exposure b. Develop desensitization to trauma c. Often develop PTSD d. May become confused or afraid 20. A child who demonstrates impaired performance on school work following a natural disaster is displaying a(n) ________ reaction. a. Emotional b. Cognitive c. Physical d. Interpersonal 21. Vicarious trauma refers to the development of trauma symptoms in ________ secondary to stories of others’ traumatic experiences. a. Children b. Counselors c. Parents d. Society 22. A child who is emotionally withdrawn, lacks empathy and remorse and lacks social responsiveness is most likely to be diagnosed with: a. Acute stress disorder b. Disinhibited social engagement disorder c. Post-traumatic stress disorder d. Reactive attachment disorder 23. A child who is overly emotional and overly needy and clingy with adults is most likely to be diagnosed with: a. Acute stress disorder b. Disinhibited social engagement disorder c. Post-traumatic stress disorder d. Reactive attachment disorder

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25. A child who describes experiencing flashbacks, hyperarousal, and difficulty sleeping in the week following a traumatic experience is most likely to be diagnosed with: a. Acute stress disorder b. Disinhibited social engagement disorder c. Post-traumatic stress disorder d. Reactive attachment disorder 26. An example of complex trauma is: a. Witnessing a murder b. Experiencing 3 years of sexual abuse c. Being disabled in a car accident d. Losing everything in a hurricane 27. When assessing youth related to maltreatment and trauma, the first thing a counselor should assess is: a. Immediate safety b. Age when abuse began c. Medical history d. Symptoms of distress 28. The use of trauma-related checklists and assessments is: a. Inappropriate with young children b. Likely to trigger flashbacks c. Necessary to assess symptoms d. Unlikely to be reliable with youth 29. A counselor using a trauma-informed approach teaches a child how to use grounding exercises to cope with unpleasant emotions. This counselor is focusing on the goal of: a. Promoting safety b. Providing psychoeducation c. Facilitating emotional processing d. Enhancing identity 30. A counselor using a trauma-informed approach informs a child about typical reactions and effects of experiencing trauma. This counselor is focusing on the goal of: a. Promoting safety b. Providing psychoeducation c. Facilitating emotional processing d. Enhancing identity 31. A counselor using a trauma-informed approach is working with a child to create a trauma narrative. This counselor is focusing on the goal of: a. Promoting safety b. Providing psychoeducation c. Facilitating emotional processing d. Enhancing identity

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32. A counselor using a trauma-informed approach encourages a child to focus on his internal experiences and encourages him to explore likes and dislike. This counselor is focusing on the goal of: a. Promoting safety b. Providing psychoeducation c. Facilitating emotional processing d. Enhancing identity 33. When a parent is the perpetrator of abuse, ________ is typically the overarching goal. a. Placement with a relative b. Placement in foster care c. Reunification with the parent d. Severing ties to the parent 34. The acronym PRACTICE is used to highlight the counseling tasks of: a. Trauma-focused CBT b. Cognitive-Behavioral Intervention for Trauma in Schools c. Combined Parent-Child CBT d. Eye Movement Desensitization and Reprocessing 35. All of the following are steps involved in Psychological First Aid except: a. Ensuring client safety b. Providing trauma-focused counseling c. Making plans d. Obtaining commitment 36. With regard to medication, while ________ are approved for use with adults with PTSD, there is only preliminary evidence that these medications may reduce symptoms in youth. a. Anti-seizure medications b. Atypical antipsychotics c. Benzodiazepines d. Selective serotonin reuptake inhibitors

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Chapter Sixteen: Substance Abuse 1. Approximately ________ percent of youth meet criteria for a substance use disorder. a. 2% b. 5% c. 10% d. 14% 2. The presence of substance use disorders in family members is a ________ risk factor for developing a substance use disorder. a. Biological b. Psychological c. Social d. Developmental 3. Traumatic experiences represent a ________ risk factor for developing a substance use disorder. a. Biological b. Psychological c. Social d. Developmental 4. Lack of positive peer relationships represents a ________ risk factor for developing a substance use disorder. a. Biological b. Psychological c. Social d. Developmental 5. The neurochemical ________ is released whenever people engage in pleasurable activities to reinforce behaviors and increase the likelihood they will recur. a. Dopamine b. Glutamate c. Norepinephrine d. Serotonin 6. Mood-altering substances ________ dopamine in the brain, reinforcing substance use and increasing risk for a substance use disorder. a. Deplete b. Eliminate c. Increase d. Mimic 7. Substance use to cope with emotions, stress, or anxiety is most likely to occur in: a. Early childhood b. Middle childhood c. Adolescence d. Young adulthood

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8. The ________ of the brain is responsible for decision making and cost-benefit analysis and is underdeveloped in adolescents. a. Midbrain b. Limbic system c. Corpus collosum d. Prefrontal cortex 9. Brain development continues until between age: a. 18 to 20 b. 21 to 23 c. 24 to 25 d. 25 to 30 10. Social consequences for youth substance use differ from social consequences for adults due to the: a. Requirement of compulsory school attendance b. Universal nature of substance use in adolescence c. Legal responsibility of parents for minor children d. Difficulty accessing youth substance use treatment 11. If a young person becomes physiologically dependent on a substance, he or she will be likely to experience: a. Blackouts b. Depression c. Hangovers d. Withdrawal 12. The substance that cuts off the supply of oxygen to the brain and may result in death regardless of number of times or dosage used is: a. Alcohol b. Cocaine c. Heroin d. Inhalants 13. Risk of death during the withdrawal process is greatest for: a. Alcohol b. Cocaine c. Heroin d. Inhalants 14. To diagnose a substance use disorder, at least two symptoms identified in the DSM-5 must be present during a ________ -month time span: a. 3 b. 6 c. 9 d. 12

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16. The ASAM dimensions help counselors identify ________ for clients. a. Needed level of care b. Helpful medications c. Appropriate peer supports d. Educational accommodations 17. The law that protects substance use treatment records provided by federally-funded facilities is called: a. HIPAA b. 42 CFR c. IDEA d. FERPA 18. Treatment for youth substance use disorders typically involves the use of: a. Cognitive behavioral therapy b. Person-centered therapy c. Psychodynamic therapy d. Reality therapy 19. With regard to substance use disorder treatment, contingency management is: a. Ineffective with youth who use marijuana b. Difficult to manage in residential settings c. Able to be translated into the home by parents d. Rooted in unpredictable reinforcement schedules 20. The use of ________ with youth can be helpful to help them resolve ambivalence related to changing substance use patterns. a. Cognitive-behavioral therapy b. Contingency management c. Motivational interviewing d. Psychoeducation 21. The use of ________, while not considered treatment, may be useful for promoting support and accountability in youth who want to change substance use patterns. a. Group therapy b. Family therapy c. Twelve-step programs d. Motivational interviewing 22. Family involvement in treatment for youth with a substance use disorder is considered: a. Unhelpful until change occurs b. Important in later stages of treatment c. Crucial throughout the treatment process d. Inappropriate in residential treatment settings

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24. Which of the following is true regarding psychopharmacotherapy for treating substance use disorders in youth? a. Medications approved for adults are also approved for use with youth b. Most medications are used to treat the side-effects of intoxication c. Medications exist specifically designed for youth substance use disorders d. Medications are most often used to manage comorbid mental health disorders

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Chapter Seventeen: Anxiety, Obsessive-Compulsive, and Related Disorders 1. Lifetime prevalence rates for anxiety in youth range from ________ percent. a. 5-10 b. 10-15 c. 15-20 d. 20-15 2. Lifetime prevalence rates for obsessive-compulsive disorder in youth range from ________ percent. a. 1-3 b. 3-5 c. 5-7 d. 7-9 3. Very young children typically experience fears and worries that are: a. Based in reality b. Culturally bound c. Highly specific d. Universal 4. A child who reports experiencing nausea and headaches in response to anxiety is reporting symptoms in the ________ domain. a. Somatic b. Cognitive c. Behavioral d. Affective 5. Young children are most likely to describe ________ symptoms in response to anxiety. a. Somatic b. Cognitive c. Behavioral d. Affective 6. A young person’s ________ behaviors in response to anxiety represent their best attempt to manage these intense, uncomfortable feelings. a. Exaggerated b. Externalized c. Inappropriate d. Internalized 7. During the assessment process, a parent reports his child frequently cries hysterically when being dropped off for school. This child is most likely experiencing ________. a. Agoraphobia b. Panic disorder c. Separation anxiety disorder d. Specific phobia

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8. During the assessment process, a parent reports her child begins to hyperventilate and cry every time she sees a spider. This child is most likely experiencing ________. a. Agoraphobia b. Panic disorder c. Separation anxiety disorder d. Specific phobia 9. A ________ is the most effective means to assess anxiety and obsessive-compulsive disorders in youth. a. Standardized assessment b. Parent survey c. Teacher survey d. Diagnostic interview 10. A young person who reports ongoing intrusive thoughts is most likely experiencing a(n) a. Compulsion b. Obsession c. Panic attack d. Specific phobia 11. A child who experiences hair pulling in response to strong emotions is most likely to be diagnosed with: a. Obsessive compulsive disorder b. Body dysmorphic disorder c. Trichotillomania d. Excoriation disorder 12. The most evidence-based approach for youth with anxiety and obsessive-compulsive disorders is: a. Behavioral therapy b. Cognitive-behavioral therapy c. Reality therapy d. Solution-focused therapy 13. A counselor who is using imagery and music to help youth tolerate anxiety-related situations is most likely providing: a. Relaxation training b. Affective education c. Social skills training d. Cognitive skills training 14. The goal of affective education is to help youth develop: a. Tolerance for strong emotions b. Awareness of internal experiences c. Parent-child attunement d. Behavioral coping skills

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16. A counselor who is educating a young person on the verbal and nonverbal components of interacting with classmates is most likely providing: a. Relaxation training b. Affective education c. Social skills training d. Cognitive skills training 17. A technique for helping youth develop cognitive awareness when situations become anxiety producing is: a. Modeling b. Thought records c. Shaping d. Habit reversal training 18. The process of ________ involves breaking a desired behavior into smaller parts and reinforcing the attainment of those parts. a. Modeling b. Contingency management c. Shaping d. Habit reversal training 19. A behavioral approach to treating various body-focused repetitive behaviors is: a. Modeling b. Contingency management c. Shaping d. Habit reversal training 20. Exposure-based procedures are based on ________ and the assumption that if clients can better tolerate fearful situations, over time they will experience extinction of the anxiety. a. Contingency management b. Classical conditioning c. Operant conditioning d. Cognitive restructuring 21. With regard to psychopharmacology for anxiety and obsessive-compulsive disorders, research: a. Supports medication use with anxiety disorders only b. Supports medication use with OCD only c. Supports medication use with both anxiety disorders and OCD d. Does not support medication use for either disorder

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Chapter Eighteen: Depressive and Bipolar Disorders 1. Prevalence rates for depression in youth are approximately ________ percent. a. 4 b. 11 c. 16 d. 20 2. Prevalence rates for bipolar disorder in youth are around ________ percent. a. 1 b. 3 c. 5 d. 7 3. A young person who is experiencing an elevated mood without an impact on functioning is most likely experiencing a ________ episode. a. Manic b. Hypomanic c. Depressive d. Mixed-features 4. In younger children, depression is frequently expressed through ________ symptoms. a. Behavioral b. Cognitive c. Physical d. Interpersonal 5. A young person is most likely to manifest symptoms of depression as negative selfimage and self-loathing during: a. Early childhood b. Middle childhood c. Late childhood d. Adolescence 6. Behaviors associated with depression in youth include all of the following except: a. Changes in sleep b. Changes in appetite c. Unresponsiveness to criticism d. Difficulty concentrating 7. A young person who experiences chronic low mood or irritability most of the time on most days is most likely to be diagnosed with: a. Disruptive mood dysregulation disorder b. Major depressive disorder c. Persistent depressive disorder d. Premenstrual dysphoric disorder

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9. A ________ is the most effective means to assess for depressive disorders in youth. a. Standardized assessment b. Parent survey c. Teacher survey d. Diagnostic interview 10. As part of any assessment for depressive disorders in youth, counselors must: a. Administer standardized assessments b. Conduct a urine drug screen c. Assess symptoms of mania and hypomania d. Collect collateral data from parents and teachers 11. Masked depression describes depressive symptoms that are: a. Attributed to a behavioral disorder b. Caused by a medical condition c. Concealed by the young person d. A result of abuse or neglect 12. A young person reports experiencing little need for sleep, intense feelings of euphoria, and the belief that she is going to be filming a movie next week. This is most likely to be symptomatic of: a. Premenstrual dysphoric disorder b. A manic episode c. A hypomanic episode d. A mixed episode 13. Inappropriate affect in youth with bipolar disorder is most likely to include: a. Lack of emotional expression b. Excessive anger and rage c. Silliness and giddiness d. Tearfulness and sadness 14. A child reports experiencing chronic fluctuations in affect and energy, and states these shifts have never impaired functioning or resulted in symptoms of major depressive disorder. The most likely diagnosis for this child is: a. Bipolar I disorder b. Bipolar II disorder c. Cyclothymic disorder d. Disruptive mood dysregulation disorder 15. Coupled with a strong therapeutic relationship, the use of ________ is the most effective approach for treating bipolar disorder in youth. a. Reality therapy b. Cognitive behavioral therapy c. Solution-focused therapy d. Adlerian therapy

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17. A counselor who is working with a young person with bipolar disorder to explore the impacts of symptoms and issues on the client and family is most likely focusing on: a. Affective education b. Coping and problem-solving skills c. Cognitive restructuring d. Developing positive beliefs about oneself 18. A counselor who is working with a young person with bipolar disorder to challenge automatic negative thoughts is most likely focusing on: a. Affective education b. Coping and problem-solving skills c. Cognitive restructuring d. Developing positive beliefs about oneself 19. A client who is experiencing social withdrawal and decreased engagement in hobbies or schoolwork would most benefit from: a. Activity scheduling b. Affective education c. Cognitive restructuring d. Problem-solving skills 20. With regard to family involvement, ________ often becomes a central component of a comprehensive approach when working with youth with depressive or bipolar disorders. a. Early childhood recollections b. Parent training c. A parent support group d. Sibling social skills development 21. Youth with depression are most likely to benefit from: a. Anticonvulsants b. Atypical antipsychotics c. Mood stabilizers d. Selective serotonin reuptake inhibitors 22. Despite evidence suggesting their utility, the U.S. Food and Drug administration has not approved ________ for use with youth with bipolar disorder. a. Anticonvulsants b. Atypical antipsychotics c. Mood stabilizers d. Selective serotonin reuptake inhibitors 23. In young people, there is an increased risk of suicidality with: a. Anticonvulsants b. Atypical antipsychotics c. Mood stabilizers d. Selective serotonin reuptake inhibitors

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Chapter Nineteen: Physical Health-Related Counseling Issues 1. In ________ youth may present with a persistent lack of recognition of the seriousness of their condition. a. Anorexia nervosa b. Binge eating disorder c. Bulimia nervosa d. Both anorexia and bulimia 2. The typical age of onset for both anorexia and bulimia is age: a. 10 b. 12 c. 14 d. 16 3. The mortality rate for anorexia nervosa is approximately ________ per decade. a. 1 b. 3 c. 5 d. 10 4. In treating bulimia nervosa, ________ was associated with positive treatment outcomes. a. Group-based treatment b. Rapid reduction of symptoms c. Gradual behavior change d. Higher weight at intake 5. A young person who reports engaging in excessive exercise, eating 400 calories per day, and maintaining a significantly low body weight is most likely to be diagnosed with: a. Anorexia nervosa, restricting type b. Anorexia nervosa, binge eating/purging type c. Bulimia nervosa d. Other specified feeding or eating disorder 6. With anorexia nervosa, a medical assessment is necessary: a. Only with youth below 70% of their body weight for height b. Only with youth who are purging c. Only with youth who experience cardiac symptoms d. With all clients who have anorexia nervosa 7. Co-occurring disorders that are like to occur with anorexia nervosa include all of the following except: a. Bipolar disorder b. Depressive disorder c. Obsessive compulsive disorder d. Oppositional defiant disorder

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8. With regard to bulimia nervosa, a binge involves the consumption of an objectively large amount of food over the span of no more than: a. 1 hours b. 2 hours c. 3 hours d. 4 hours 9. The prevalence rate of bulimia in adolescents approximately: a. 1% b. 3% c. 5% d. 9% 10. Approximately ________ of youth with bulimia nervosa are male. a. 1-2% b. 5-10% c. 10-15% d. 15-20% 11. A serious potential medical consequence of bulimia nervosa includes: a. Infertility b. Osteoporosis c. Seizures d. Heart failure 12. The most effective treatment modality for anorexia nervosa in youth is: a. Cognitive behavioral therapy b. Family-based treatment c. Psychodynamic therapy d. Dialectical behavior therapy 13. A key component of the Maudsley method is: a. Emotional awareness and regulation skills b. Mindfulness-based coping skills c. Parental control over the refeeding process d. Early childhood recollections 14. Effective treatments for bulimia nervosa include all of the following except: a. Cognitive behavioral therapy b. Family-based treatment c. Psychodynamic therapy d. Dialectical behavior therapy 15. With regard to eating disorders, psychopharmacotherapy research suggests medication is: a. Effective for anorexia nervosa only b. Effective for bulimia nervosa only c. Effective for both anorexia and bulimia d. Not effective for either disorder 75 ..

16. Enuresis is not able to be diagnosed before age: a. 3 b. 4 c. 5 d. 6 17. Enuresis is not able to be diagnosed before age: a. 3 b. 4 c. 5 d. 6 18. Before considering a diagnosis of enuresis or encopresis, counselors must rule out: a. Behavioral disorders b. Anxiety disorders c. Mood disorders d. Underlying medical conditions 19. Symptoms of enuresis must occur at least twice per week for ________ consecutive months. a. 3 b. 6 c. 9 d. 12 20. Enuresis affects up to ________ percent of children ages five through twelve. a. 9 b. 19 c. 29 d. 39 21. Environmental reasons that may cause youth to inappropriately urinate include: a. A relative who experienced similar symptoms b. Incomplete formation of neurological pathways between bladder and brain c. Excessive caffeine consumption d. Stressful family dynamics 22. Encopresis is characterized by inappropriate voiding of feces at least once every ________ months. a. 3 b. 6 c. 9 d. 12 23. An example of encopresis without constipation and overflow incontinence is encopresis as a result of: a. Harsh potty training methods b. Fear of using the bathroom c. A damaged colon d. A desire to express disapproval 76 ..

24. The most effective treatments for elimination disorders focus on: a. Behavioral interventions b. Cognitive interventions c. Psychodynamic interventions d. Solution-focused interventions 25. Between ________ million youth age 17 and younger have at least one chronic health problem. a. 5-8 b. 10-13 c. 15-18 d. 20-23 26. A chronic illness that targets the gastrointestinal and respiratory system that may cause malnutrition and respiratory infections is: a. Cerebral palsy b. Sickle cell anemia c. Cystic fibrosis d. Spina bifida 27. During early school-age, youth typically: a. Lack understanding of their illness and its implications b. Understand what it means to be sick but lack awareness of implications c. Understand reasons for the illness, though reasons may be illogical d. Understanding their illness and the effects it has on them and others 28. Many parents of children with chronic medical conditions experience: a. Anhedonia b. Apathy c. Grief d. Detachment 29. A parent of a child with a chronic illness that reports experiencing poor sleep is experiencing a(n): a. Internal stressor b. External stressor c. Physiological stressor d. Psychosomatic stressor 30. Effective interventions for youth with chronic medical conditions include all of the following except: a. Behavioral therapy b. Cognitive behavioral therapy c. Person-centered therapy d. Solution-focused brief therapy

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Answer Key Chapter One 1. C 2. D 3. A 4. D 5. B 6. D 7. A 8. C 9. A 10. C 11. D 12. B 13. B 14. A 15. A 16. B 17. D 18. C 19. B 20. B 21. C 22. C 23. B 24. B 25. C 26. A 27. D 28. C 29. B 30. B 31. A 32. D 33. C 34. D 35. D Chapter Two 1.

2.

3.

4.

5.

6.

7.

8.

9.

D B C A C A A B D 78 ..

10. B 11. A 12. A 13. D 14. C 15. A 16. B 17. D 18. D 19. D 20. A 21. C 22. C 23. A 24. D 25. C 26. A 27. C Chapter Three 1. B 2. A 3. C 4. C 5. C 6. A 7. C 8. D 9. C 10. B 11. D 12. C 13. C 14. D 15. B 16. A 17. A 18. B 19. C 20. B 21. C 22. B 23. A 24. B 25. D 26. D 27. C 28. B 29. C 79 ..

30. B 31. C 32. B Chapter Four 1. C 2. A 3. D 4. B 5. D 6. C 7. D 8. D 9. B 10. A 11. A 12. C 13. A 14. D 15. B 16. A 17. C 18. B 19. D 20. D 21. C 22. A 23. B 24. C 25. A 26. D 27. B 28. C 29. C Chapter Five 1. B 2. A 3. D 4. C 5. B 6. A 7. B 8. D 9. A 10. B 11. D 12. D 80 ..

13. B 14. D 15. A 16. C 17. A 18. B 19. B 20. A 21. C 22. D 23. B 24. C 25. C 26. B 27. D 28. A 29. C 30. B 31. B 32. A 33. C 34. D 35. B 36. D 37. B 38. D 39. C 40. B 41. B 42. B Chapter Six 1. A 2. D 3. B 4. A 5. C 6. A 7. B 8. C 9. D 10. B 11. C 12. C 13. D 14. D 81 ..

15. D 16. A 17. D 18. A 19. A 20. A 21. B 22. D 23. A 24. D 25. C 26. A 27. B 28. C 29. C 30. C 31. D 32. C Chapter Seven 1. C 2. B 3. B 4. B 5. A 6. C 7. C 8. A 9. D 10. B 11. B 12. A 13. C 14. C 15. C 16. D 17. A 18. D 19. B 20. C Chapter Eight 1.

2.

3.

4.

B D A B 82 ..

5. D 6. B 7. C 8. D 9. D 10. C 11. C 12. A 13. B 14. D 15. C 16. C 17. A 18. B 19. C 20. A 21. B 22. A Chapter Nine 1. C 2. C 3. B 4. C 5. A 6. C 7. B 8. C 9. B 10. C 11. B 12. D 13. A 14. B 15. D 16. A 17. C 18. B 19. C 20. C 21. C 22. A 23. A 24. D 25. B 26. C 83 ..

27. C 28. D Chapter Ten 1. C 2. B 3. D 4. A 5. B 6. D 7. B 8. B 9. A 10. A 11. C 12. C 13. A 14. C 15. D 16. B 17. B 18. B 19. C 20. C 21. D 22. B Chapter Eleven 1. C 2. B 3. B 4. D 5. B 6. A 7. C 8. D 9. B 10. A 11. A 12. C 13. B 14. C 15. B 16. B 17. A 18. B 84 ..

19. D 20. C Chapter Twelve 1. C 2. C 3. A 4. B 5. B 6. B 7. C 8. A 9. B 10. C 11. D 12. A 13. D 14. B 15. D 16. B 17. C 18. B 19. D 20. C 21. D 22. C 23. A 24. A 25. B 26. D 27. A 28. B Chapter Thirteen 1. A 2. C 3. B 4. B 5. B 6. D 7. C 8. A 9. D 10. C 11. B 12. C 85 ..

13. A 14. C 15. D 16. D 17. C 18. A 19. D 20. B 21. B 22. D 23. A Chapter Fourteen 1. C 2. D 3. D 4. B 5. C 6. B 7. B 8. B 9. C 10. B 11. C 12. B 13. B 14. C 15. D 16. C 17. A 18. C 19. B 20. C 21. C Chapter Fifteen 1. D 2. D 3. D 4. B 5. A 6. B 7. B 8. D 9. D 10. C 86 ..

11. C 12. A 13. A 14. D 15. A 16. C 17. D 18. D 19. B 20. D 21. B 22. A 23. B 24. A 25. C 26. A 27. B 28. C 29. D 30. C 31. A 32. B 33. D Chapter Sixteen 1. B 2. A 3. B 4. C 5. A 6. C 7. C 8. D 9. D 10. C 11. D 12. D 13. A 14. D 15. A 16. B 17. A 18. C 19. C 20. C 21. C 87 ..

22. D Chapter Seventeen 1. B 2. A 3. D 4. A 5. A 6. D 7. C 8. D 9. D 10. B 11. C 12. B 13. A 14. B 15. C 16. B 17. C 18. D 19. B 20. C Chapter Eighteen 1. B 2. B 3. B 4. C 5. D 6. C 7. C 8. D 9. C 10. A 11. B 12. C 13. C 14. B 15. A 16. C 17. A 18. B 19. D 20. A 21. D 88 ..

Chapter Nineteen 1. A 2. B 3. C 4. B 5. B 6. D 7. D 8. B 9. A 10. C 11. D 12. B 13. C 14. C 15. B 16. C 17. B 18. D 19. A 20. B 21. D 22. A 23. D 24. A 25. C 26. C 27. C 28. C 29. C 30. C

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Counseling Children and Adolescents First Edition

Chapter 1 Developmentally Informed Youth Counseling

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Youth Mental Health Overview • Twenty percent of youth in adolescence have a diagnosable mental health disorder • Approximately 50% of mental health disorders develop before age 14

• Early intervention helps keep problems from escalating • Prevention is also a goal of counselors working with youth

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Youth Development Overview • Development is the process of growth and maturity – Physical – Cognitive – Personal (self) – Social (psychosocial) – Emotional • Youth develop at different rates (Delayed/accelerated) • Influenced by biological, psychological, social, and family factors • Counselors value a developmental perspective across the lifespan • A developmental focus is especially useful for working with youth Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Risk and Protective Factors • Risk factors inhibit healthy growth and development • Protective factors, also called resiliency factors, promote development • Risk and protective factors work synergistically and interact

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Physical Development • Includes physical growth, including visible (i.e., height, weight) and invisible (i.e., brain, organs) changes • Risk factors: – Genetic variations and birth defects – Understimulating environment – Child abuse and neglect – Malnourishment • Protective factors: – Small child-to-caregiver ratio – Emotional regulation development – Safe and secure relationships – Stimulating environments Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Cognitive Development • Continual formation of thought that supports cognition (i.e., information processing, problem solving, reasoning, memory, communication) • Piaget’s stage model of cognitive development: – Sensorimotor (birth-age two)

– Preoperational (age 2-7) – Concrete operational (age 7-11) – Formal operational (age 11-16)

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Self Development • Concept of self is formed through early childhood attachments with caregivers • Self-concept includes mental representations of abilities and characteristics • Self-esteem is one’s overall sense of worth and value • Parents and caregivers have significant influence on young children • Peer influences increase as children become adolescents

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Psychosocial Development • Characterized by thoughts, feelings, and experiences stemming from relational contexts and interactions • Self-worth informed by interactions with others • Attachment in early childhood influences later relationships • As development progresses, autonomy and initiative increase • Resolution of Erikson’s psychosocial crises promotes trust, positive sense of self, and sense of importance

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Early Childhood Overview • Includes children ages 3 to 5 years old • Parents should be integral part of counseling for this age group • Referrals will likely come from parents, teachers, or social services • Older siblings may also be focus of services with systemic interventions

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Early Childhood: Physical Development • Increasing neuron connections between brain and all parts of body • Stimulating activity increases neuronal connections • Physical growth and muscle development occur • Gross and fine motor skills increase • Genetic risk factors (i.e., Down Syndrome), chronic stress, and depression in home may negatively impact physical development

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Early Childhood: Cognitive Development • Most rapid brain development occurs in first 2 years • Begin forming pre-academic skills (i.e., counting, alphabet) • Messages from adults about academic success can have longterm impact • Cognitive deficits can have long-lasting impact on achievement in school • Piaget’s stages during early childhood: – Sensorimotor (birth to 2): Parts of brain that control emotions, physiological arousal, and emotional regulation are used most – Preoperational: (2-7): Begin understanding language, symbolic objects, and other forms of symbolism

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Early Childhood: Self-Development • Youth begin to recognize themselves as unique and distinct from others • Temperament influences development of sense of self • Sets the stage for positive self-concept and self-esteem across the life span • Self-development in early childhood is heavily influenced by others

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Early Childhood: Psychosocial Development • Begins with attachment to parents and expands due to social interactions in childhood • Influenced by attachment in early childhood • Secure attachments promote trust • Erikson’s stages in early childhood: – Trust versus mistrust – Autonomy versus shame and doubt – Initiative versus guilt • Unmet basic needs may negatively influence psychosocial development

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Early Childhood: Emotional Development • Young children experience a range of emotions (i.e., happiness, surprise, disgust, sadness, anger, fear) • Awareness of emotions in self and others is limited • Begin learning through recognition of facial expressions • Environment conducive to healthy emotional expression is important for emotional development • Developmental disabilities such as autism spectrum disorder may impact emotional identification and regulation • Social skills training may support young people who struggle with emotional regulation and expression Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Early Childhood: Common Problems • Mental health difficulties often expressed behaviorally • Temper tantrums, aggression, or failure to adhere to ageappropriate norms • Transitions, trauma, and developmental difficulties may all be triggers • Ineffective environmental reinforcers may promote problematic behaviors

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Early Childhood: Counseling Applications (1 of 2) • • • • • •

Attend to child’s basic needs during sessions Integrate family into counseling as much as possible Use verbal and physical expression to engage and soothe Pace with child’s attention span in mind Promote active role and autonomy in sessions Use play to affirm self-concept and self-development

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Early Childhood: Counseling Applications (2 of 2) • • • • •

Use simple, clear, concrete language Model appropriate behaviors and emotional expression Consider using group interventions for social skills Keep groups brief and focused Encourage social interaction in groups

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Middle Childhood Overview • • • • • •

Ages 6-12 Bridges early childhood and adolescence Self-consciousness and independence emerges Social relationships outside of family increase Development of social skills and sense of self Increasing independence and confidence in middle childhood prepare children for adolescence

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Middle Childhood: Physical Development • Growth differences become more dramatic in middle childhood • Height, weight, muscle development, and motor skills change at varying rates • Girls’ growth tends to occur earlier than boys’ growth • Early and late maturation occur in both genders • Changes associated with puberty begin • Extra calories and nutrients may be needed during this stage to promote healthy growth

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Middle Childhood: Cognitive Development (1 of 2) • Brain develops rapidly, especially prefrontal lobe • Youth enter Piaget’s concrete operational stage • Increases in planning, reasoning, and problem solving occur • Neural connections increase, which promotes new learning • Myelination and selective pruning crystallize some behaviors

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Middle Childhood: Cognitive Development (2 of 2) • Abstract thinking is still a challenge • Academic skills develop and are encouraged in schools • ADHD, ODD, and learning disabilities may manifest during this stage • Active, engaging learning tasks are optimal • Social cognition also develops during this stage

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Middle Childhood: Self-Development • Youth often define themselves by their activities, things, and appearance • Begin justifying perceived characteristics • Increase identity separate from family • Begin judging parents and questioning them and their ideas • Become more able to care for themselves • Begin thinking through actions and consequences • Friendships evolve and peer involvement increases • Comparing self to others and wanting to ‘fit in’ increase

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Middle Childhood: Psychosocial Development • • • •

Social relationships become more important Moral reasoning develops Communication skills increase, as does sense of humor Teachers and schools set norms and rules for social interactions • Academic performance becomes increasingly important and informs view of self • Attachment to adults other than parents may occur and impact self-worth

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Middle Childhood: Emotional Development • Increasing self-control results from increased problem solving skill • Emotional regulation and emotional complexity increase • Self-consciousness increases • Friendships are defined by loyalty and support • Winning, leading, or being first is valued • Emotional sensitivity emerges

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Middle Childhood: Common Problems • Struggles with transitions and disruptions in routines • Difficulties coping with increasing independence • Family-related struggles (i.e., separation, divorce, sibling conflict, meeting family responsibilities) • Academic and social difficulties • Bullying • Behavioral problems in school

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Middle Childhood: Counseling Applications • Provide support for organizing thinking, problem-solving, and decision-making • Use structure based on developmental milestones and needs • Include youth in setting goals and agendas for counseling • Provide opportunities to talk through and consider options for addressing problems • Increase autonomy and ownership for role in counseling • Integrate family as appropriate • Increase emotional identification and coping strategies • Promote creative self-expression through art, writing, reading, etc.

• Consider group counseling to promote social, self- and emotional development Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Early Adolescence Overview • • • • •

Youth 10-14 years old Relationships outside of family increase Interests, values, and attitudes are explored and solidified Confusing, exciting, and difficult time for youth Independence increases, which presents opportunities and challenges

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Early Adolescence: Physical Development • Rapid physical growth is hallmark of this stage • Timing and rate of growth is variable within and across youth • Onset of puberty, which is influenced by genes and environment • Girls tend to experience puberty earlier than boys, which may influence opposite sex relationships • Sexual changes and urges promote consideration of sexual identity • Cerebellum and frontal lobes of the brain continue developing

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Early Adolescence: Cognitive Development • Transition into Piaget’s formal operational stage • Increasingly abstract thinking and development of causeeffect thinking • Able to consider multiple alternatives for resolving problems • Inconsistencies in thinking abstractly across different domains

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Early Adolescence: Self-Development • Increase in competence, independence, and identity • Erikson’s stage of identity versus role confusion • Identity formation involves encountering crises and formulating commitment to identity – Identity foreclosure – Identity diffusion – Identity moratorium – Identity achievement • Increasing autonomy and separation from parents, turning toward peers for support and affiliation • Egocentrism increases

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Early Adolescence: Psychosocial Development • • • •

Peer relationships increase in importance Reliance on parental influence decreases Group norms and a desire to fit in emerge Bullying, relational aggression, and popularity are common social concerns • Emotional regulation, problem solving, and conflict management skills can help youth cope with social stressors and relationships • Comparison to peers is common and informs identity and interests

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Early Adolescence: Emotional Development • • • •

“Emotional rollercoaster” Emotions may shift quickly and intensely Emotions may distance youth from peers and adults Concrete thinking and increased anxiety may lead to guilt and shame • Increased vulnerability to anxiety and depression

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Early Adolescence: Common Problems • Problems often stem from difficulties in emotional regulation, identity, and peer or family struggles • Anxiety disorders, behavioral disorders, and depressive disorders are most common in this age group • Eating disorders or related symptoms may occur in vulnerable youth

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Early Adolescence: Counseling Applications • Consider tasks that help youth explore who they are and what they are good at • Attend to youth attention span when considering session activities • Integrate parents whenever possible • Use peer-based interventions when possible • Focus on client interests and avoid power struggles • Promote increased empathy and insight for others • Integrate popular culture when appropriate • Consider group interventions for social supports, normalizing experiences, increasing empathy and perspective-taking, and coping Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Late Adolescence Overview • Youth 15-18 • Less vulnerability than early adolescence • Increased emotional expression • Tends to be more emotionally stable than early adolescence

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Late Adolescence: Physical Development • Physical growth slows, although growth spurts may still occur (especially in boys) • Sexual changes continue and sexual maturity occurs • Sexual exploration and curiosity continues, which may increase risks associated with sexual activity (i.e., sexually-transmitted diseases, pregnancy, etc.)

• Sexual identity continues to be an area of focus and may cause anxiety for LGBTQ youth • Increase in risk taking associated with incomplete brain development (i.e. substance use, unprotected sex, accidents)

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Late Adolescence: Cognitive Development • Piaget’s formal operational stage evolves during late adolescence • More flexibility in thinking and ability to consider consequences and alternatives • Increasing attention to potential possibilities and evolving opinions in moral, social, and political domains • Inconsistency in thinking may still occur due to lack of experience and self-understanding • Problem-solving skill development may decrease risktaking behaviors and impulsivity

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Late Adolescence: Self-Development • Unconscious preoccupation with establishing identity and seeking independence • Vocational, political, social, sexual, moral, and religious values and beliefs may evolve during this time • Expanding interests and identities may occur during this stage • Ethnic and cultural identities may evolve and contribute to selfdevelopment • Uniqueness is important and stems from increased selfconfidence • Desire for uniqueness may be protective against peer pressure • Some youth may continue to experience peer pressure and bullying • School, extracurricular, and prosocial activities may be protective against negative peer influences Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Late Adolescence: Psychosocial Development • Peer relationships continue to be very important • Increase in tolerance for individual differences • Develop more intimate friendships and partner relationships • Intentionality surrounding friendships • Personal identity evolves as a byproduct of social pressures

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Late Adolescence: Emotional Development • • • •

Fewer mood fluctuations than early adolescence Increased insight into emotions More capable of expressing emotions Emotional maturity may decrease conflict with parents, siblings, peers • Increased empathy and decreased impulsivity compared with early adolescence • Youth may experience self-doubt, grow apart from support systems, and become apprehensive about their future

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Late Adolescence: Common Problems • Similar to those in early adolescence • Identity development, vocational considerations, risk-taking behaviors, relationship and family conflicts • Anxiety, depression, and behavioral disorders most common mental health concerns • Substance use, truancy, fighting, and illegal activity are often causes for initiation of counseling in this stage • Peer and family relationships may become strained • Sexuality and sexual identity may present concerns for some youth • Increasing reliance on technology and social media may create problems related to socialization, loneliness, depression or anxiety, and cyberbullying Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Late Adolescence: Counseling Applications • Consider developmental purpose of increased experimentation and risk taking • Draw upon client’s expertise on him or herself • Explore social relationships • Be genuine and authentic in interactions with late adolescents • Engage youth by using creative, experiential., and interesting counseling activities • Explore developmental issues and consider developmental contexts when considering concerns and interventions • Consider group counseling to promote interpersonal skills and provide psychoeducation

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Copyright

This work is protected by United States copyright laws and is provided solely for the use of instructors in teaching their courses and assessing student learning. Dissemination or sale of any part of this work (including on the World Wide Web) will destroy the integrity of the work and is not permitted. The work and materials from it should never be made available to students except by instructors using the accompanying text in their classes. All recipients of this work are expected to abide by these restrictions and to honor the intended pedagogical purposes and the needs of other instructors who rely on these materials.

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Counseling Children and Adolescents First Edition

Chapter 2 Systemically Informed Youth Counseling

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Context and Culture (1 of 3) • Counselors practice from holistic perspective—all aspects of clients’ lives are interconnected • Context includes factors and conditions surrounding clients • Culture, including gender and ethnicity, influences how youth define, express, and interpret beliefs, values, customs, and role expectations • 2014 ACA Code of Ethics emphasizes that counselors should consider cultural factors

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Context and Culture (2 of 3) • Wide variation exists between individuals of different cultures regarding perspectives on “normal” behaviors • Culture may influence perceptions of behavior, acceptability of behaviors, and response to behaviors • Culture informs how individuals and communities respond to stressors and challenges and when and from whom help-seeking may occur

• Socioeconomic status and social position also influence manifestation and response to perceived problems in youth

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Context and Culture (3 of 3) • Non-White individuals will make up the majority of the U.S. population by the year 2044 • Counselors should broach topics of race, socioeconomic status, gender, and other multicultural factors and avoid making assumptions

• Microaggressions—racially biased oppression that is communicated in subtle and covert ways—and discrimination may impact youth • Culturally sensitive counselors are aware of the role of power and oppression as they relate to client concerns, risks, and access to resources and support

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Strength-based Philosophy (1 of 2) • Youth’s strengths and resilience are essential resources in supporting development • Strength-based philosophy is grounded in the assumption that development and amplification of strengths and assets provides them with greater resilience against future difficulties • Counselors actively enhance, develop, and highlight client strengths, resources, and previous resilience, coping, and perseverance

• Focusing on strengths increases self-determination, selfesteem, internal fortitude, and mastery of life

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Strength-based Philosophy (2 of 2) • Strength-based counseling shifts away from focusing on problems and toward focusing on capacity, resources, strengths, and supports • Prevention programs that teach cognitive and coping skills and focus on character strengths and virtues such as responsibility, gratitude, nurturance, and altruism, may increase resilience and decrease risks • Resilience, or the ability to resist against difficulties, can be enhanced by promoting autonomy, social competence, problem solving, and sense of purpose.

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Family Risk Factors • Emotional, physical, or sexual abuse or neglect

• Overindulgence in childhood • Ineffective or harsh communication, limited parental involvement, unclear or rigid boundaries, triangulation, and enmeshment

• Intimate partner violence • Intergenerational trauma • Lack of financial resources

• Family members with physical, mental, or emotional difficulties • Change in family structure Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Family Protective Factors • Clearly defined rules and expectations • Clearly defined yet flexible family subsystems and boundaries • Consistent and reasonable discipline • Expression of warmth and love • Financial resources • High levels of support and involvement within family • Strong cultural identity and religious values • Youth living with one or both parents

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School Risk Factors • • • • • • • •

Bullying and delinquent peer influences Ineffective classroom management Lack of academic resources Negative expectations from teachers and staff Mental health disorders that impact learning Past experiences of academic difficulties Racism and other prejudices School violence

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School Protective Factors • • • •

Effective classroom management Experiences of academic competence and success Positive expectations from teachers and staff Positive peer influences, trusting friendships, and feelings of social connectedness • Academic resources • Monitoring and advocacy from school personnel • Youth motivation for achievement

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Community Risk Factors • Devaluation of education • Community violence, crime, and drug and weapon availability • High residential mobility • Immigrating from another country or culture • Lack of supportive institutions • Lack of nonparent role models

• Poverty, including moving from low-poverty to highpoverty neighborhoods • Racism and prejudice

• Unfair social policies Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Community Protective Factors • Advocacy initiatives • Collaborative partnerships between government agencies and community leaders • Afterschool programs, social, and sport clubs • Community engagement and education • Discouragement of drugs and violence • Limited access to guns and violence • Value of education • Youth leadership and volunteer opportunities

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Family Structure and Boundaries • Family is a social unit that may include biological, step-, adoptive parents, siblings, aunts, uncles, grandparents, cousins, and even friends or neighbors • Family structure includes the people included in a family • Youth may define their family structure in different ways • Counselors should focus on youth’s subjective definition of family and attend to intentional exclusions that might indicate risk • Ethnic identity and traditions play a significant role in how youth define and understand family structures

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Family Structure and Boundaries • Family structures change over time, including when new members join the family, when existing members leave the household, when family members move to or from the household temporarily, and when the family moves away from other family and friends • Changes in family structure may lead to feelings of grief and contribute to interpersonal struggles or academic problems if left unresolved • Family boundaries are rules and norms that inform daily interactions between family members • Olson’s Circumplex model explains that predictable yet flexible rules and roles and a balance between connection and independence are optimal Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Family Communication • Family boundaries, values, expectations, and approvals are conveyed through communication • Limited, ineffective, or harmful communication increases risk • Communication of love and support are influenced by family of origin experiences, culture, and life experiences • Counselors can support families in learning and using effective communication skills

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Family Involvement and Support • Involves ways in which parents and other adults in the family ensure needs are met • Influenced by culture, values, boundaries, and communication styles • Lack of involvement increases risk • Support may be impacted in single-parent households, low SES households, families in which parents are caregivers for their parents, and families with a child who has a mental health disorder • Overindulgence can also increase risk, as children learn to seek instant gratification

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Child Maltreatment • Includes child abuse and child neglect

• Abuse includes physical, emotional or sexual aggression • Neglect involves the failure of caregivers to provide adequate emotional and physical resources

• Eighty percent of the 3.5 million reported cases involved neglect; assessing for both abuse and neglect is essential • Effects are diverse and depend on many factors • While long-term negative effects occur, most children do not develop ongoing traumatic reactions secondary to the maltreatment and may even experience post-traumatic growth • Protective factors can offset the risks of child maltreatment Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Violence in the Home • Intimate partner violence (violence in the home) can have serious negative impacts on youth, even if the young person is not physically involved

• Both men and women may be perpetrators or victims • Youth who witness violence in the home have increased risk

• Protective factors may offset these risks in youth, including mental health intervention for the family, police involvement, and presence of siblings in the home • Counselors can help youth express emotions, challenge irrational and unhelpful thoughts, and promote family coping Copyright © 2019 Pearson Education, Inc. All Rights Reserved

School System Risk and Protective Factors • School influences academic, career, and personal and social development • Microcosm for youth to learn about themselves, others, and the world • Academic abilities, family influences, school climate, and peer relationships may serve as risk or protective factors

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Family Influences on Academic Development •

Behaviors at school are intimately connected to home environments and vice versa

•

Stressors in the home may negatively affect school performance and behavior, and stressors at school may negatively affect home behavior

•

Young people with helpful familial influences are more likely to succeed in school and adapt to school environment

•

Family structure and boundaries influence academic beliefs and values

•

Poverty may decrease education as a priority, and counselors should work with youth and families to promote positive views of school and education Copyright © 2019 Pearson Education, Inc. All Rights Reserved

School Climate • School climate is created through interaction of factors including teacher/staff attitudes and behaviors, interpersonal relationships, resources, classroom management, and school safety • Poor teacher expectations and negative attitudes from staff have a negative impact on youth • Poor classroom management decreases feelings of safety and increases uncertainty that may increase risk of behavior problems • Protective factors include positive expectations, consistency in rules, promoting success, identifying strengths, and access to learning resources Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Peer Relationships • Peer relationships in the school setting may present risk or protective factors • Youth learn about themselves, their preferences, values, strengths, and weaknesses through interactions with peers

• Feeling understood and accepted by peers is a protective factor against many challenges, including peer pressure and high-risk situations • Poor peer relationships, negative influences, bullying, and feeling unsafe are social risk factors for youth in school • Peer relationships are a strong indicator of social and interpersonal adjustment Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Bullying • Bullying may increase risk and feelings of being unsafe in school and spillover settings • Physical or emotional bullying, in person or online, involve one person putting down or attacking another • Youth who bully may have a history of being bullied or victimized in the home, low IQ or learning disorders, substance use, poor emotional control/regulation, or antisocial values • Long-term impacts of bullying include mental health problems, anxiety, depression, and suicidal ideation, especially for youth who bully others in response to bullying Copyright © 2019 Pearson Education, Inc. All Rights Reserved

School Violence • Includes physical fights, gang activity, and use of deadly weapons against peers or school staff • Risk factors include previous aggression, substance use, delinquent peer group, poor family boundaries/communication, academic struggles, and poverty • Counselors should work to educate school staff, promote positive school climate, and intervene early to promote coping, social skills, positive relationships with youth and adults in the community, safety, connectedness, and positive values

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Community Risk and Protective Factors • Community refers to shared environment and/or the people within it • Youth dependence on family for community exposure highlights interconnection between family and community • Community rules, norms, and resources may be risk or protective factors • Community violence and crime are risk factors for youth • Youth who belong to racial, ethnic, sexual, or socioeconomic minority groups may be at increased risk for difficulties • These youth may find respite in communities where similar shared identities exist among community members

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Community and Neighborhood Norms (1 of 2) • Norms are mutually-agreed upon behavioral standards that inform social organization and interaction • Community norms are influenced by values and standards of overall society and community members • Acculturation—or adaptation of youth who emigrated from another country to the new culture—can be difficult for immigrant youth and challenges for immigrant youth and families may arise from these cultural differences • Community protective factors include value for education and academic progress, respect for human life, safe and stable interpersonal relationships, and promotion of individual identity and self-esteem Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Community and Neighborhood Norms (2 of 2) • Sports programs may promote teamwork, self-discipline, and healthy coping • Community identity may be a protective factor or a risk factor • Racism, sexism, and discrimination negatively impacts youth, especially those in impoverished communities

• Limited access to resources and difficulty coping with delayed gratification may decrease value for education in disadvantaged communities • Living in depressed or dysfunctional communities increases risk for difficulties among youth • Community resources can be accessed to offset these risks Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Neighborhood Violence and Crime • Up to 75% of youth have been exposed to some form of neighborhood violence in the U.S. • Exposure to neighborhood violence and crime increases risk of experiencing difficulties in youth • Protective factors include safety within the home, relationships with positive adults and peers in community and school • Access to and relationships with positive role models • Youth taking on leadership positions, volunteering, and connecting with spiritual resources are also protective factors

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Technology • Exposure to technology continues to rise among youth and provides access to worldwide community • Both risk and protective factors exist related to technology

• Excessive time spent online can be isolating and may decrease interactions with family and peers • Access to pornography and violence also present risks for youth • Promoting family rules and expectations around technology and providing youth with opportunities to examine risks and benefits of technology alongside inperson interactions promote positive development in youth

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Copyright

This work is protected by United States copyright laws and is provided solely for the use of instructors in teaching their courses and assessing student learning. Dissemination or sale of any part of this work (including on the World Wide Web) will destroy the integrity of the work and is not permitted. The work and materials from it should never be made available to students except by instructors using the accompanying text in their classes. All recipients of this work are expected to abide by these restrictions and to honor the intended pedagogical purposes and the needs of other instructors who rely on these materials.

Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Counseling Children and Adolescents First Edition

Chapter 3 Individual Counseling Foundations

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Individual Counseling Foundations • Counseling, at the most basic level, is two or more people coming together so the counselor can help clients make changes, live more optimally, or prevent problems from occurring • Youth generally present to counseling to work on problems either they or those around them identify • Effective counseling foundations are similar for adults and youth, however consideration of developmental factors is essential when counseling youth

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Foundations of the Counseling Process (1 of 3) • Counseling research suggests counseling with youth is just as effective as counseling with adults • Youth who participate in counseling fair better than those who don’t receive counseling and change may occur quickly • Outcomes do not favor a particular theoretical approach and are not dependent on license or degree of the provider • The counseling relationship is the single most important aspect of the individual counseling process • Certain behaviors facilitate strong counseling relationships

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Foundations of the Counseling Process (2 of 3) • Effective youth counselors…

– Have advanced interpersonal skills – Form a working alliance with a diverse array of clients – Provide explanations of clients’ problems that are acceptable, adaptive, and culturally sensitive – Provide counseling or treatment plans consistent with how the problem is conceptualized – Monitor client progress in counseling – Are flexible and adjust counseling approaches as needed and appropriate

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Foundations of the Counseling Process (3 of 3) • Effective youth counselors…

– Address difficult counseling topics and material – Communicate hope, enthusiasm, and optimism – Demonstrate sensitivity to clients’ personal characteristics – Are self-aware and engage in ongoing reflection – Focus on continuous improvement as a counselor – Remain aware of the research and use it to select appropriate counseling approaches

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Preliminary Counseling Considerations • Preliminary counseling tasks lay the foundation for individual counseling with youth • Relevant to all counseling regardless of theoretical orientation • Preliminary counseling considerations include the physical setting, informed consent, development of therapeutic relationship, and assessment of presenting concerns • Typically occur in first 1-3 sessions, but may be constrained due to setting/environment (e.g., school counseling) • Followed by working stage of counseling Copyright © 2019 Pearson Education, Inc. All Rights Reserved

The Physical Setting • Young clients are particularly sensitive to the environment • Counselors should create an age-appropriate physical space for conducting counseling comfortably • Avoid dramatic décor, maintain consistency with room structure, and provide appropriate lighting • Sit at eye level with the client and avoid seating client too low or in positions that disempower client

• Counselors should avoid sitting behind a desk but may have a table for counseling activities • Create a distraction-free space

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Media • Employ developmentally-appropriate media

• Too many games, toys, or decorations can distract clients • Provide access to toys that are appropriate to clients’ development and promote exploration and expression • Fidget toys such as stress balls, silly putty, etc., may help clients self-regulate, promote calmness, and encourage focus • Create a space with easy access to drawing surface and materials • Consider maintaining a basket of toys, games, and reading material in the waiting area Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Snacks and Incentives • Counselors should decide whether they will have snacks for clients available upon request • Young clients may be thirsty or hungry when presenting to counseling and may struggle to focus if needs aren’t met • Obtain parental consent prior to providing snacks

• Providing treats at the end of session may distort boundaries and support manipulation • It may also be developmentally and culturally appropriate

• If using treats, they should not be contingent on behavior or participation in session

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Predictable Structure • Counseling experience should be comfortable, relaxed, and safe

• Predictability and consistency promote feelings of security • Start and end sessions on time • Provide description of structure to clients so they know what to expect • Communicate limits and boundaries to clients, such as expectations about cleaning up, not taking items home, and using items for intended purposes

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Intake and Assessment • First 1-2 sessions are referred to as the client intake • Legally, guardians must provide consent for minors to engage in counseling and should attend intake session • Process includes review of informed consent and assessing counseling situation and needs • Use of facilitative listening skills promotes connection • Tasks include gathering and synthesizing information, reviewing legal and ethical matters, setting counseling expectations, and focusing on therapeutic counseling

• Informed consent process should be thorough and involved guardians and clients if it is age appropriate Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Confidentiality • Legally, young clients have no confidentiality rights, as parents have access to all records • Many youth, especially teens, may not want parents to have unlimited access to their experiences

• Counselors should discuss expectations and boundaries regarding confidentiality with parents and explain importance of some degree of confidentiality for youth

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Assessment (1 of 2) • Assessment is an ongoing process that begins during the first sessions and continues throughout the counseling process • The I CAN START model can be used to assess situation and context of client concerns • Initial prompts may encourage clients to describe a typical day or ideal day and ask clients what they perceive as being the reason for being in counseling

• Counselors should assess family and others’ perceptions of the problem as well • Counselors may use media or toys to collect information

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Assessment (2 of 2) • Solution-focused brief therapy approaches may be helpful for assessing what clients would like to change • Phrasing of questions should be adapted to age and developmental level of youth

• Mental status exam should consider physical, cognitive, developmental, environmental, and historical experience and presentation • Consider observing client in the natural environment • Counselors may also use tests, surveys, and scales to objectively assess and quantify client concerns and strengths

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Review of Counselor and Client Expectations (1 of 2) • Listen for client’s expectations and hopes for counseling • Convey information on what counseling can and cannot do • Educate client and family on roles related to counseling • Describe counseling approach, beliefs about change, and methods used • Duration and frequency of sessions should be discussed • Explore client and parent expectancies regarding the effectiveness of and confidence in counseling process

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Review of Counselor and Client Expectations (2 of 2) • Clarify expectations of and for parents within counseling process • Younger children may experience fear or uncertainty about the counseling process, so exploring and addressing these concerns is important • Clarify why client is attending counseling and address misconceptions • Explain approaches and rationale for selecting treatments and interventions to clients and parents

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Family Structure and Boundaries • Family structures change over time, including when new members join the family, when existing members leave the household, when family members move to or from the household temporarily, and when the family moves away from other family and friends • Changes in family structure may lead to feelings of grief and contribute to interpersonal struggles or academic problems if left unresolved • Family boundaries are rules and norms that inform daily interactions between family members • Olson’s Circumplex model explains that predictable yet flexible rules and roles and a balance between connection and independence are optimal Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Structuring Counseling (1 of 2) • Counseling structure will be determined based on client needs and concerns • Structure includes length of sessions, duration of time in counseling, and frequency of sessions for client and/or family • Balancing predictability and flexibility is important • Decisions about when or if meeting with parents is appropriate are informed by many factors • Parental engagement of some kinds is important in promoting change

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Structuring Counseling (2 of 2) • Meeting with young clients’ parents alone during first session is generally advised to gather information and model appropriate boundaries • Meeting with the whole family together in the first session provides opportunities for observation • Meeting with young child alone during first session provides additional information and promotes rapport • Beginning and ending sessions in consistent ways helps provide structure and safety

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The Working Alliance • Developing the counseling relationship is an important early task of counseling • A strong therapeutic relationship is necessary for counseling work to progress • Working alliance involves a relational bond, agreement on goals, and agreement on tasks • Seeking feedback from clients and families regarding goals, direction, and approaches promotes working alliance • Working alliance is correlated with outcomes across counseling approaches

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Challenges to the Working Alliance • Limited problem recognition/awareness • Belief that external factors are cause of problems • Low motivation to change

• Lack of understanding of or value for counseling process • Mistrust of counselor or counseling, especially among adolescents and mandated clients/families • Abuse, trauma, or neglect that impacts trust of adults • Lack of interest or ability for verbal expression • Disorders and disabilities that influence verbal communication Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Relationship Building Strategies • Empathy, congruence, positive regard, and affirmation

• Awareness of clients’ perceptions of the counselor and the impact this has on counseling relationship • Spending time focusing on relationship building and connecting with clients • Less structure in early sessions may promote engagement with tasks in later sessions • Exploring client interests, likes, and dislikes

• Taking slow and steady approach to discussing difficult topics • Addressing ambivalence as “the elephant in the room” Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Working Stage Counseling Considerations • Working stage includes counseling after preliminary tasks are addressed • Working stage may vary based on presenting issues, development, and family involvement • Theoretical approach, setting, and session limits also impact working stage

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Communication Approaches (1 of 2) • Involves both verbal and nonverbal communication • Use of nonverbals should be intuitive and artful

• Eye contact and leaning forward are associated with counseling outcomes • Cultural variations in nonverbal communication should be acknowledged and responded to sensitively

• Play is a form of communication natural for young children • Behaviors are also tools for communication in youth

• Counselors should use clients’ language and style • Convey the purpose of communication in counseling Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Communication Approaches (2 of 2) • Skills and techniques can promote communication

• Open-ended questions invite more thoughtful responses but may pose challenges to young children • Using too many questions may confuse or frustrate clients • Youth typically lack insight, so asking ‘why’ is likely to be ineffective • Listening, paraphrasing, and reflecting are more useful skills to elicit information and engage young clients

• Consider using activities and approaches that engage youth creatively in counseling process

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Motivation and Change • When clients are ready to change, counseling is more effective • Mandated clients and adolescents in particular may have little motivation to change • It is the counselor’s job to help clients find motivation to change

• Building trust increases engagement and motivation • Most counseling approaches assume clients are motivated to change • Assessing and addressing motivation before proceeding with change-focused interventions is essential Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Enhancing Motivation to Change • Low motivation to change may arise at any point in the counseling process • Motivation may vary based on behavior and context • Motivational interviewing is an approach focused on helping clients resolve their own ambivalence about change • MI foundations include collaboration, evocation, and autonomy • By not forcing change, clients have autonomy and may be more engaged in counseling process

• Stages of change—precontemplation, contemplation, preparation, action, maintenance, and relapse/termination— help counselors conceptualize client readiness to change

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Precontemplation Goals and Tasks • Goal: Consider possibility that client has an issue • Tasks: – Assess overall health, wellbeing, strengths, skis, and cultural concerns – Develop rapport through empathy – Address safety issues – Enhance awareness of self, problem, and behaviors – Active listening and reflect change talk – Enhance awareness of advantages of change and downsides of problem behaviors – Educate client on risks

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Contemplation Goals and Tasks • Goal: Increase awareness of the problem • Tasks: – Emphasize autonomy and personal responsibility – Assess cultural issues – Acknowledge strengths, skills, and values – Validate ambivalence toward change – Normalize change process – Explore pros and cons of behavior – Elicit self-motivational statements – Provide specific feedback

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Preparation Goals and Tasks • Goal: Increase commitment to change through small steps • Tasks: – Explore options and barriers to change – Discuss what has worked previously for client – Help client set realistic expectations – Empower and aid client to create manageable goals – Brainstorm small steps toward change – Provide information and ideas on strategies for change – Introduce coping strategies and skills – Identify a network of social support Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Action Goals and Tasks • Goal: Create and implement action plan with support • Tasks: – Develop action plan with timeline – Keep steps incremental and achievable – Practice and review coping strategies/skills – Reinforce efforts and small successes – Affirm strengths and skills – Reiterate long-term benefits – Enlist help and increase social support

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Maintenance Goals and Tasks • Goal: Review counseling gains and potential difficulties • Tasks: – Review counseling gains and potential difficulties – Review coping strategies/skills – Plan for follow-up support – Reinforce internal rewards – Continue to seek supports – Discuss plan for future – Explore warning signs of relapse and how to respond

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Technology and Counseling • Technology can be used in and out of session to help clients change

• Computers, tablets, and other electronics can be used in session with therapy applications and games • Applications may also be used with the family and client in session or outside of session • Use of technology may facilitate engagement and between-session practice of skills

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Termination • Termination is the process of finalizing or ending a counseling experience • Termination represents a finale, commencement, and time of new beginnings • Natural termination occurs when counseling goals have been met and all parties agree to end counseling • Premature termination occurs when counseling stops before goals are achieved • Final counseling sessions are just as important as early sessions • Termination is a process that requires ongoing assessment and attention, rather than a one-time event Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Natural Termination • Reasons include positive progress, goal attainment, and improved functioning relative to the focus of counseling • Natural termination may not mean the end of client’s engagement in counseling

• Discussions of termination should begin at onset of counseling • Discussions should focus on goals, time to achieve them, and signs of progress in relation to termination • Explain termination as a positive and natural outcome of counseling • Attention to termination early in counseling may increase motivation and commitment to change Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Signs of Termination Readiness • Clients and families self-report successes or readiness to terminate

• Observing positive changes in client behavior • Decreased frequency or intensity of counseling • Positive reaction to discussions about termination

• Absenteeism, tardiness, or early departure from sessions • Increased focus on matters unrelated to counseling • Openness to different ways of thinking and problem solving • Increased tolerance and management of emotions • Functional independence from counseling process Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Termination Readiness Complexities • Assessment of progress may be complex depending on client concerns, issues, and individualized nature of counseling • Clients may experience new struggles • Thought of termination may promote increase in problems

• Termination may trigger feelings of loss and grief • Loss of the counseling relationship may be difficult for youth • Assessing and addressing termination anxiety is important • Positive termination experience can be corrective for youth with history of loss and abandonment • Counselors must reflect on own feelings about termination

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The Termination Process • Clients are empowered and therapeutic gains highlighted • Reinforcement of clients’ hard work, identification of aspirational future goals, and ways clients can meet goals • Appointments may be scheduled further apart to assess change with fewer counseling contacts • Ask youth/families when they want to have next session • Collaborate to develop termination plan with client that addresses referrals, warning signs, high-risk situations, and steps for seeking support if concerns re-emerge • Address changes in boundaries and relationship if continued contact will occur (e.g., school counselors)

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Termination Activities • Involve creative aspect that highlights progress, makes sessions memorable, and provides closure

• Draw upon client interests when selecting activity • Eases transition and brings life to counseling process when client concerns are decreasing • Using transitional objects, art, and rituals can bring meaning and creativity into termination process

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Premature Termination • Between 40-60% of counseling ends prematurely • Younger clients may be at even grater risk of premature termination than adults • Presenting concerns may increase risk of not attending • May be initiated by counselor, client, or parents or may be a result of factors outside of anyone’s control • May occur as improvements begin for client and family believes counseling is not needed • Transportation, insurance, illness, relocation, financial barriers, or scheduling may all cause premature termination

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Family Expectations and Premature Termination • Families with mistaken beliefs or unclear expectations surrounding counseling may be less engaged • Parents may be limited in ability to support between-session tasks • Beliefs that counseling is unhelpful impact engagement

• Parental beliefs that counseling is helpful increase engagement and follow-through • Financial stability, steady insurance, and community support promote engagement

• Discussions regarding expectations early in counseling process and ongoing progress updates promote engagement Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Culture and Premature Termination • Up to 69% of ethnic minority youth leave counseling prematurely • Low SES is another risk factor for premature termination • Low income, single parent, ethnic minority families with lower educational attainment, poor academics, family history of mental illness, and subsided housing support are more likely to drop out of counseling • Culture may emphasize keeping family concerns within the family and lead to mistrust of counseling • Counselors should be sensitive to factors that influence early termination with relation to culture

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Avoiding Premature Termination • Develop strong therapeutic relationship and working alliance with client and family early in counseling • Explore benefits of counseling and how counseling works • Communicate clear expectations to clients and families

• Assess satisfaction with counseling process • Develop positive relationships with client and family to avoid triangulation

• Become comfortable explaining expectations and communicating with family members • Maintain regular communication with families and other stakeholders Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Termination and Referral • Providing clients with referrals to other providers if ongoing services are needed during termination process is necessary • May stem from need for different level of care or due to counselor’s inability to meet client needs • Self-awareness of counselor strengths and limitations can support appropriate referrals • Consultation and supervision are important when considering referral of clients • Termination process should be attended to in cases of referral • School counselor referral should be considered at the end of school year and when clients are transitioning settings

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Copyright

This work is protected by United States copyright laws and is provided solely for the use of instructors in teaching their courses and assessing student learning. Dissemination or sale of any part of this work (including on the World Wide Web) will destroy the integrity of the work and is not permitted. The work and materials from it should never be made available to students except by instructors using the accompanying text in their classes. All recipients of this work are expected to abide by these restrictions and to honor the intended pedagogical purposes and the needs of other instructors who rely on these materials.

Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Counseling Children and Adolescents First Edition

Chapter 4 Ethical and Legal Foundations

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Individual Counseling Foundations • Counseling, at the most basic level, is two or more people coming together so the counselor can help clients make changes, live more optimally, or prevent problems from occurring • Youth generally present to counseling to work on problems either they or those around them identify

• Effective counseling foundations are similar for adults and youth, however consideration of developmental factors is essential when counseling youth

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Ethical and Legal Foundations (1 of 2) • Children’s rights should be a top priority • Counselors are required to understand laws and ethics surrounding protecting youth rights • Counselors frequently experience conflicts between ethical obligations and legal requirements • Parental and guardian rights are also considerations • School counselors must also consider school administrators and other children • Many counseling-related conflicts can be avoided if they view parents as partners • Counselors should balance rights of parents with rights of minors Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Ethical and Legal Foundations (2 of 2) • Minors are youth who are not capable of taking care of or making decisions for themselves • Minor status may vary depending on state laws and is not always age 18

• Minors have the right to be provided with information that will help them actively participate in counseling • Minor client assent should be sought prior to initiating and making decisions in counseling

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Defining Ethical and Legal Matters (1 of 2) • Ethics and law are two different things • Ethics involves counselors behaving in moral, virtuous, or principled ways and taking action that supports client wellbeing

• Counselors must adhere to professional ethical codes for guidance and use ethical decision-making models for resolving ethical dilemmas • Laws are created and enforced through the legal system, not through the profession • Laws indicate minimum acceptable standards for behavior • Violation of laws may result in civil or criminal punishment Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Defining Ethical and Legal Matters (2 of 2) • Counseling associations and certification bodies uphold ethical principles

• State licensure boards uphold legal requirements • Federal laws may also affect how counselors approach different situations • Conflicts between ethical and legal issues may arise • Professional literature provides little guidance on how to address conflicts between ethics and laws • Counselors should be aware of ethical, state, and federal legal codes relevant to their work with clients

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Competence • Competence includes having knowledge, skills, and diligence to effective function and meet professional obligations and standards • Despite requirements for youth-specific training, counselors are likely to work with youth and their families • Education, training, and supervised practice are essential in developing competence • Ethical and legal standards of competence protect clients from harm and malpractice • No current professional competencies exist related to working with youth

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Minors’ Rights and Legal Consent to Counseling • Balance between guardians’ legal rights and ethical obligation to clients must be considered • State-level regulations govern whether clients may initiate counseling without parental consent; in most states, guardians must provide consent • Age of consent also informs whether youth may initiate counseling without parental consent • States may have different laws governing youth consent for specific issues or under specific circumstances • Counselors should be aware of specific laws that govern consent with regard to specific client populations Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Informed Consent/Assent (1 of 3) • Counselors are required to assure that clients understand nature of counseling and make informed decisions about pursuing counseling during intake process • Informed consent is the formal action of consenting to counseling after being provided with all relevant information • Guardians must sign informed consent paperwork, although they may not fully understand meaning behind it • Assent is provided by minors who agree to, but cannot legally consent to, participation in counseling

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Informed Consent/Assent (2 of 3) • Informed consent information should include: – Limits of confidentiality – Counselor’s theoretical approach and techniques – Counselor’s license/credential information – Mandates for reporting child maltreatment – Notices of privacy practices and client rights – Information on coordinating treatment – Procedures regarding emergency situations, missed appointments, and payments/missed payments

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Informed Consent/Assent (3 of 3) • Nature of relationship with youth and family members/other stakeholders should be established when initiating counseling • In divorce situations, both parents should provide consent • Regular review of consent parameters with family and stakeholders relative to development of youth is important • Counselor should engage in ongoing discussion of informed consent as client ages and matures • Discussions of informed consent should be conducted in developmentally-appropriate fashion

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Confidentiality (1 of 3) • Privacy refers to rights of people to decide what will be shared or withheld from others • Confidentiality is an ethical concept founded on the idea of privacy within the context of a professional relationship • Privileged communication is a legal concept that refers to laws protecting clients from having confidential information shared in courts without express permission • Minor confidentiality rights highlight the push and pull between ethical and legal obligations • Parents generally have legal access to all counseling information, but counselors have an ethical duty to protect confidential information of young clients

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Confidentiality (2 of 3) • Privacy in counseling promotes engagement and trust, but laws do not generally protect youth privacy over parental rights • Developmental considerations related to privacy are important, especially during adolescence • Reviewing confidentiality expectations and requirements during the informed consent progress with client and families is essential to establishing guidelines and expectations • Parents should be made aware of harmful youth behaviors • Ambiguity around behaviors that are not considered imminently dangerous may make discerning necessity of disclosure complex

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Confidentiality (3 of 3) • Consider practical, legal, and ethical aspects of situations • Choosing to withhold information from parents means counselors are assuming full legal responsibility should an implicating circumstance occur • Parents generally have the right to know about treatment; if a counselor is unsure, it may be better to share information • Counselors should discuss disclosure to parents with clients before, during, and after disclosure • Counselors should strive to uphold confidentiality as much as possible while sufficiently informing caregivers • Empowering client to share information with family is ideal Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Informed Consent/Assent and Confidentiality in School Settings (1 of 2) • School counselors generally do not have a legal obligation to obtain parental consent unless indicated in state laws • Parents may request for a child not to receive services • Informed consent is generally difficult or impossible for school counselors to obtain due to youth development • School counselors should weigh benefits versus risks of providing counseling services • School counselors should avoid coercion if another adult is pushing youth into counseling • Persistent efforts should be made to obtain informed consent from parent/guardian Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Informed Consent/Assent and Confidentiality in School Settings (2 of 2) • School counselors balance ethical obligation to students with parent/guardian legal rights • Historically, privacy rights belonged to parents and have been protected by court decisions • School counselors should be clear about limits of confidentiality and the kinds of information that will be shared with parents and school staff • Information should be shared in least intrusive manner possible • Only necessary information should be shared

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Child Maltreatment Reporting • Youth safety is a counselor’s first priority • All states in the U.S. have mandated reporting laws that require counselors to report instances of suspected abuse or neglect to a governmental agency • Neglect occurs more frequently than abuse, despite the increased attention paid to child abuse • Youth-initiated child abuse also generally requires report • Norms regarding acceptable punishments vary across cultures • Child maltreatment as defined by the counselor’s jurisdiction must legally be reported regardless of culture

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Counselors’ Personal Reactions to Reporting • It can be uncomfortable for counselors to report suspected maltreatment • Counselors should be aware of personal reactions and impacts on judgement • Concerns regarding trust or retaliation may occur • Cynicism surrounding effectiveness of reporting may also influence decision to report • A child’s safety must always take precedence • State statutes protect mandated reporters from retaliation • Consultation and documentation of rationale can also be protective and are important in the reporting process Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Statutory Requirements and Reporting • Laws vary by state, but typically require a report to be made whenever the counselor suspects abuse or neglect • In some states, requirements also mandate reporting of situations that may reasonably result in harm • States vary in terms of who reports, what is reported, to whom report must be made, confidentiality of report, whether past abuse must be reported, time frame of report, and which categories of perpetrators is required • Knowing what to report and when may be confusing, especially related to neglect and past abuse/neglect if the youth is no longer in danger Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Should a Report Be Made?

• Use of clinical judgement is necessary • Maltreatment is rarely directly reported and more likely to be suspected over time working with youth • Determining whether abuse or neglect is present may be challenging with ambiguous information • Emotional abuse and neglect may be particularly difficult to define • Nature and extent of evidence may be difficult to interpret • Consultation promotes ideas for ongoing data collection and decision-making regarding reporting • Counselors can consult with child protective agencies regarding whether information is sufficient to report Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Making a Report (1 of 2) • Facts and circumstances must be reported • Report must be made in jurisdiction where abuse occurred • Information reported may include: – Name and birthdates/ages of parties involved – Address of subjects of the report – Child’s school – Relationship between perpetrator and child – When and where incident occurred – Details of situation causing the report – Whether there are witnesses to abuse/neglect

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Making a Report (2 of 2) • Counselors should provide as much information as they have, but may not have all information requested • Document report in case notes by recording date/time of call, summary of the report, and name of person contacted • Consider providing counselor information for follow-up • Agencies and institutions may have specific protocols for reporting child abuse/neglect, including informing administration or supervisors • Mandated reporting may impact counseling relationship, especially in poorly-handled cases • Counselors must assess and address immediate safety concerns in reporting situations by using safety plans Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Family Structure and Boundaries • Child protective services will conduct an investigation if they decide one is warranted • They will apply a finding/disposition to the case, typically that child maltreatment is indicated, founded, or unfounded • The agency will report findings to law enforcement • Law enforcement will progress with legal proceedings • Child protective services may contact the counselor throughout process • Counselor is advised not to provide information to unverified investigators, but to cooperate after verification • School counselors are encouraged to cooperate with and be aware of laws regarding in-school interviews Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Health Insurance Portability and Accountability Act (HIPAA) • Applies to organizations and individuals who transmit healthcare information electronically • Requires providing clients with information on how they retain, use, and disclose healthcare-related information • Clients are required to have access to their records • Process for clients to amend records must be in place • Designation of a privacy officer to oversee management and handling of confidential records • Counselors must provide information on records handling, disclosures, and access • Generally guardians make decisions for minors regarding protective health information, though some exceptions exist Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Family Educational Rights and Privacy Act (FERPA) • All counselors who work in federally-funded school settings are bound to FERPA guidelines • Safeguards confidentiality of educational records • Educational records include any information related to the student maintained by an educational agency, intuition, or party acting on the institution’s behalf • Requires guardians’ written consent to release records and protects guardians’ right to view and amend records • Schools may disclose records without consent under specific circumstances outlined by FERPA • Once youth turn 18, they have legal right to protect records Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act (42 CFR) • Applies to agencies that receive federal funding and provide substance use treatment or services • Protect clients due to stigma and risk of prosecution stemming from seeking substance use disorder treatment • Describe circumstances under which treatment information may be disclosed • Release of client information requires court order or guardian written consent • Clients can not be identified to persons outside treatment setting without written consent • Records cannot be used in legal investigations Copyright © 2019 Pearson Education, Inc. All Rights Reserved

The Schools and Disability: IDEA and Section 504 (1 of 2) • Individuals with Disabilities Education Act (IDEA) was enacted in 1975 to ensure children with disabilities receive a free public education that meets individual learning needs

• Applies to any school that receives federal funding to accommodate youth who have a physical or mental disability • Individualized Education Plans (IEPs) are documents developed for youth who have a disability to describe special education provisions • Accommodations and provisions of IEPs are regularly reviewed and updated and help youth access the learning environment and content equitably

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The Schools and Disability: IDEA and Section 504 (2 of 2) • Section 504 of the Rehabilitation Act of 1973 requires that public schools provide free and appropriate education to students with physical or mental impairment that limits one or more life activities • 504 Plans describe accommodations to provide equitable access to academic content and environment • School counselors are generally active in developing IEPs and 504 Plans

• Clinical counselors should be familiar with these plans to appropriately support and advocate for youth

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Child Custody • Custody matters create complexities for youth counseling

• Emotions may run high and may increase guardedness in parents • Counselors may make mistakes or overstep boundaries • Counselors should remain aware of custody agreements and non-guardian rights • Obtaining informed consent from all legal guardians is essential • Counselors may be asked to become involved in custodyrelated legal proceedings • Knowledge of state regulations and attorney consultation are essential in these cases

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Consent for Treatment • State laws govern who has legal responsibility for consenting to treatment, accessing treatment records, and being involved in counseling process • Counselors should request copies of documents relevant to verifying custodial guardianship • Both parents typically have custody unless legal custody has been granted to one parent • Obtaining informed consent from both guardians in shared custody situations is essential • Exploring custody may yield useful information about family dynamics and promote family agreement about counseling Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Custody Proceedings (1 of 3) • Counselors may become entangled in custody battles and are obligated to address situations competently and ensure disputes do not impact work with youth • A guardian may seek counseling to have the counselor make recommendations regarding custody • Counselors should be cautious when in these situation and communicate that it is not the counselor’s role to make recommendations without specifically contracting to do so • Typically, custody evaluations are contacted by the court with providers with expertise in this area • Counselors should refrain from making custody recommendations without specialized training to do so Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Custody Proceedings (2 of 3) • Counselors who do work with legal system should avoid dual relationships with clients, as evaluative role is typically incompatible with therapeutic role

• Informed consent regarding involvement in legal proceedings may help prevent and troubleshoot subpoenas • Including information in the informed consent regarding a counselor’s refusal to testify in custody cases may increase trust with client and decrease likelihood of being called to testify

• Counselors may still be court ordered to testify or provide records and should consult state laws and an attorney prior to proceeding Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Custody Proceedings (3 of 3) • Legal bodies are unconcerned with counselor scope of practice, legal liability, or repercussions of counselors’ overstepping legal obligations to share information • State laws may provide guidance to counselors regarding how to respond to legal requests for information • Counselors who are required to testify should provide only facts and withhold personal opinion • Counselors must work to preserve relationships with clients and parents while also meeting legal requirements

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Multiple Relationships (1 of 2) • Multiple (dual) relationships occur when the counselor fulfills multiple roles with a client and his/her family • May include personal, familial, business, or financial relationships • Should be avoided; in practice, environment and circumstances may make avoiding them difficult • School counselors have unique challenges related to dual relationships due to their many roles within schools • Clinical counselors may face challenges due to work duties and community-based factors • Power differential between client and counselor increases risk of negative impact on clients of dual relationships Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Multiple Relationships (2 of 2) • Managing multiple relationships can be stressful and lead to emotional conflicts • Supervision and consultation can help with decisionmaking process regarding multiple relationships • Counselors should engage in self-reflection regarding entering into multiple relationships with clients • Lack of awareness or foresight may jeopardize licensure status and result in ethical inquiries, especially when client harm due to multiple relationships was avoidable • Counselors must maintain healthy boundaries and inform clients of risks of multiple relationships

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Ethical Decision Making: Practical Suggestions (1 of 4) • Be thorough and thoughtful – Carefully consider and define the problem – Consider ethical principles and virtues – Identify desired outcomes and consider all possible ways to achieve them – Document communications

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Ethical Decision Making: Practical Suggestions (2 of 4) • Be sensitive and aware of self and others – Be aware of personal attitudes, values, and beliefs – Pay attention to your feelings – Work to understand clients’ contexts and cultural background – Make decisions in the best interest of clients – Practice within your scope of practice

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Ethical Decision Making: Practical Suggestions (3 of 4) • Be transparent and communicative – Inform clients and guardians of limitations of counseling – Encourage family involvement in counseling – Develop well-articulated explanation of what you do as a counselor – Involve clients and guardians in decision making – Obtain thorough informed consent

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Ethical Decision Making: Practical Suggestions (4 of 4) • Be educated – Engage with professional counseling associations – Be aware of and practice profession’s ethical standards – Be aware of laws in state of practice • Be support seeking – Have a group of people with whom you can consult – Maintain professional liability insurance and consult with an attorney – Engage in self-support and self-care

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An Ethical Decision-Making Model: DIRECTION • Develop ethical sensitivity and awareness • Identify when there is a problem • Review and apply ethical codes and standards, legal considerations, and professional literature • Examine personal values, reactions, and context • Consult with and obtain guidance from supervisors, colleagues, and other professionals • Take possible courses of action into consideration • Interpret possible consequences of these actions • Obtain best course of action based on research and information gathered • Note outcomes of decisions and reflect on actions Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Copyright

This work is protected by United States copyright laws and is provided solely for the use of instructors in teaching their courses and assessing student learning. Dissemination or sale of any part of this work (including on the World Wide Web) will destroy the integrity of the work and is not permitted. The work and materials from it should never be made available to students except by instructors using the accompanying text in their classes. All recipients of this work are expected to abide by these restrictions and to honor the intended pedagogical purposes and the needs of other instructors who rely on these materials.

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Counseling Children and Adolescents First Edition

Chapter 5 Counseling Theories that Focus on Thought and Behavior Change and Action

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Counseling Theories that Focus on Thought and Behavior Change and Action (1 of 5) • Counselors use theories to organize and simplify the vast amount of information clients present • Theories serve as roadmaps for change and inform how to use strengths to help clients • Theories present ways of conceptualizing goals, concerns, and procedures for counseling • Behavioral, cognitive behavioral, and reality therapies focus on thought and behavior change

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Counseling Theories that Focus on Thought and Behavior Change and Action (2 of 5) • Behavior therapy focuses on action-oriented behavioral changes • Clients unlearn maladaptive behaviors and replace them with adaptive behaviors • Highly structured, active approach with demonstrated efficacy with a variety of youth issues • Also useful with families

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Counseling Theories that Focus on Thought and Behavior Change and Action (3 of 5) • Cognitive-behavioral therapy addresses thoughts and behaviors by addressing how thoughts affect emotions, moods, and actions • CBT is especially relevant for working with youth and may have lasting impacts on coping • Altering faulty thinking and developing coping skills are developmentally congruent for youth

• CBT holds that thoughts influence emotions and changing thinking impacts emotions and behavior Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Counseling Theories that Focus on Thought and Behavior Change and Action (4 of 5) • CBT helps client identify and respond adaptively to maladaptive cognitions, which should impact subsequent behavior • CBT has an extensive research base for working with youth and families • Issues germane to CBT include depression, behavioral disorders, suicidal ideation, anxiety, eating disorders, and adjustment challenges

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Counseling Theories that Focus on Thought and Behavior Change and Action (5 of 5) • Reality therapy focuses on problem-solving and addresses here-and-now actions and choices • Developed specifically for use with youth • Emphasizes making decisions, taking personal responsibility, taking action, and assuming control over one’s life • Based on idea that clients seek understanding of wants and needs and benefit from behaviors that bring them closer to these wants and needs • Less empirical support than BT and CBT Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Behavior Therapy (1 of 4) • Applies scientific method and learning principles of classical and operant conditioning to produce observable behavioral change • BT emphasizes – Assessment of objective behaviors and identification of target behaviors – Determination of function of behaviors and response to consequences – Selection of interventions to systematically extinguish unwanted behaviors and reinforce desired behaviors – Ongoing assessment and monitoring of behavior to determine effectiveness of interventions Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Behavior Therapy (2 of 4) • BT is deliberate, targeted, and methodical • Process is highly structured, active, and learning oriented • Involves unlearning maladaptive behaviors and replacing them with behaviors that promote adaptive functioning • Traditional BT emphasized learning principles, but newer models place emphasis on the effective of cognitions, emotions, and biological factors related to behavior • May be used to modify undesirable behaviors, facilitate skill development, target symptoms of distress

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Behavior Therapy (3 of 4) • Interventions include: – Modeling – Shaping – Chaining – Homework assignments – Response cost strategies – Token economy systems – Behavioral rehearsal/role-playing

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Behavior Therapy (4 of 4) • Interventions include: – Social skills and assertiveness training – Progressive muscle relaxation – Reciprocal inhibition – Systematic desensitization – Exposure-based interventions – Hypnosis – Biofeedback, self-management – Mindfulness

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BT: Core Concepts and Goals of Counseling • Views children as blank slates, neither good nor bad, simply products of their environment • Behavior is acquired through learning and conditioning • Youth develop predictable patterns of behavior in response to specific events or conditions • Behavior patterns can be changed with behavioral interventions • BT does not attend to insight, internal conflicts, fostering selfactualization and instead attends to action • BT assumes all behavior is learned and can be unlearned, viewing behavior change as empowering approach Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Classical Conditioning • Also known as respondent conditioning • Involves stimulus-response pairing process that yields the desired response when presented with stimulus

• Systematic desensitization uses classical conditioning to reduce anxiety and fear • Pairs relaxation techniques with ranked anxiety-provoking situations to extinguish anxious response

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Operant Conditioning • Also known as instrumental conditioning • Many BT interventions use operant conditioning principles • Uses consequences and reinforcements to change behavior • Rewards reinforce and increase likelihood of behaviors • Punishments and lack of reinforcers decrease likelihood of behaviors • Positive reinforcement, negative reinforcement, punishment, and extinction techniques are used to change behaviors • Positive reinforcement is the most effective of these • Generalization occurs when behavior is demonstrated in different settings

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Social Learning • Also called social cognitive theory • Focuses on client worldview, beliefs, perspectives, and other cognitive processes along with behaviors • Assumes internal appraisals and interpretations influence behavior • Informs process of learning through observing others • Particularly relevant when working with youth, who may pick up or model language and behaviors of others • Modeling provides youth with positive model or examples of behaviors they might imitate

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Role of the Counselor in Behavior Therapy (1 of 2) • Counselor serves as consultant, teacher, architect, and problem solver • Directive, planned, and instructional manner of counseling • Value systematic, objective, observable, and rigorous elements of research-based practices and procedures • View relational factors as facilitative of behavioral change • Support, encouragement, and understanding reinforces and motivates clients and families to practice new skills • Applied behavioral analysis, a systematic set of procedures, is typically used Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Role of the Counselor in Behavior Therapy (2 of 2) • ABA begins with functional behavioral assessment to determine contributing and maintaining factors of behaviors and the function these behaviors serve

• Counselors analyze data and formulate treatment goals and objectives focusing on specific, observable behaviors • Identify and teach youth behavioral interventions • Monitor behavior and assess effectiveness of treatment • Emphasize individualized treatment that considers individual, environmental, and social factors • Remain focused on developmentally-appropriate interventions and ongoing assessment Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Counseling Process and Procedures: Assessment (1 of 2) • Initial information regarding presenting concerns is gathered through direct, indirect, descriptive, and experimental methods • Seeking specific details about the behavior helps clarify function of behavior and techniques for changing it • FBAs are typically used to collect data • FBAs use the ABC model, collecting data on antecedent events, behaviors, and consequences of behavior • Functions of behavior include attention, escape, sensory, physical, and tangible Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Counseling Process and Procedures: Assessment (2 of 2) • After identifying antecedents and consequences of behavior, counselors hypothesize function of behaviors and environmental reinforcers for the behavior

• Hypotheses are tested through brief experiments • Maladaptive functional relationships inform treatment goals and objectives • FBAs are pragmatic and hold utility for youth • Client and family can be provided with concrete, logical information on the problem and process of treatment • Behavioral change promotes self-efficacy and success Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Operant Conditioning Interventions (1 of 3) • Contingency management • Token economy systems • Positive reinforcement • Negative reinforcement • Punishment • Extinction • Prompting • Shaping • Chaining

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Operant Conditioning Interventions (2 of 3) • Contingency management – Positive reinforcement – Negative reinforcement

– Punishment – Extinction • Prompting

• Shaping • Chaining

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Operant Conditioning Interventions (3 of 3) • Token economy system – Behavior contract – Reinforcement program – Response cost – Rewards for tokens earned • Counselors should remain mindful of developmental and intellectual functioning with regard to behavioral interventions • Small, manageable goals that promote success increase likelihood of change and progress toward larger goals

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Classical Conditioning Interventions (1 of 2) • • • •

Target physiological responses to stressors and trauma May also address cognitions along with behaviors Progressive muscle relaxation Systematic desensitization – Relaxation strategies – Imagining anxiety-provoking situations – Reciprocal inhibition – Counterconditioning – Anxiety hierarchy – Subjective units of distress (SUDs) – Desensitization and extinguishing Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Classical Conditioning Interventions (2 of 2) • Exposure-based interventions – In vivo exposure – Implosion – Flooding • Eye movement desensitization and reprocessing (EMDR) – Rhythmic bilateral stimulation – Imagined exposure – Relaxation – Cognitive restructuring • Many of these interventions require specialized training and should be used judiciously and ethically Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Additional Behavioral Therapy Interventions • Social skills training – Modeling – Role-playing – Homework assignments – Behavioral rehearsal • Biofeedback – Monitoring physiological activities – Control responses through use of equipment that measures biological processes

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Family Interventions and Involvement (1 of 4) • Psychoeducation can be used to educate families on how to apply interventions with their children • Provide information on assessment, treatment planning, monitoring, and assessing effectiveness of treatment • Should be provided in intellectually appropriate and culturally sensitive manner

• Provides families with education and skills to help shape behaviors of children • Parents can serve as behavioral counselors for children and promote ongoing wellness, prevention, and development

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Family Interventions and Involvement (2 of 4) • Parent management training is an evidence-based and flexible approach to addressing disruptive, noncompliant, disrespectful, destructive or other problem behaviors • Uses BT approaches, including social skills training, shaping, chaining, prompting, redirecting, and reinforcement to promote positive parent-child interactions • Fosters relational behavioral change by changing parent behaviors to promote change in youth • Communication, expectations, compromise, limit setting, discipline, school-related behaviors, practicing techniques, and providing feedback to parents are all aspects of treatment

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Cognitive Behavioral Therapy (1 of 3) • Integrates cognitive and behavioral elements • Includes the following approaches:

– Rational emotive behavioral therapy – Cognitive therapy – Mindfulness-based therapies

– Dialectical behavior therapy – Acceptance and commitment therapy – Mindfulness-based cognitive therapy

– Mindfulness-based stress reduction

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Cognitive Behavioral Therapy (2 of 3) • Merges rigor, objectivity, and systematic approach of BT with thought-based change processes of CT • Emphasis on changing beliefs, perceptions, and thinking to promote behavior change • Rest on assumption that thoughts, emotions, and behaviors all interact and changing one aspect will promote change in the other processes • Most CBT approaches emphasize the role of cognitions due to their primary role in the change process and ability to be controlled by clients • Action oriented, collaborative, didactic, present focused, and time limited interventions Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Cognitive Behavioral Therapy (3 of 3) • Extensively researched and empirically validated to address many presenting concerns • Widely accepted by third-party payers and managed care • Focus on changing thinking, developing coping skills, and enhancing problem-solving and decision making skills is congruent with developmental and learning processes • Not productive unless they are tailored to individual needs • Young children may not possess awareness of thought processes needed for CBT • Consider developmental, intellectual, and contextual factors that may impact effectiveness of CBT interventions

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Core Concepts and Goals of Counseling • Assumptions include: – Cognitive processes influence emotions and behavior – Cognitive activity can be monitored, assessed, measured and changed – Desired behavioral and affective change can be achieved by altering cognitions • Internal cognitive processes are cause of client distress and problematic behaviors • Changing thinking will change emotions and behaviors • Promote new skills and strategies for getting needs met Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Rational Emotive Behavior Therapy (1 of 2) • REBT was first CBT approach developed • Based on presumption that all individuals have capacity to think rationally and irrationally and hold predispositions for selfpreservation, growth, self-actualization, and happiness • Youth are also inclined to engage in irrational thinking and behavior, self-destruction, avoidance of actualization, selfblame, perfectionism, and repetition of past mistakes • Distress stems from inflexible, extreme, and self-defeating beliefs, misinterpreted events, and poor emotional reactions • Emphasis on role of blame and absolute should, must, ought, always, and never demands

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Rational Emotive Behavior Therapy (2 of 2) • Rigid irrational beliefs and negative self-talk emerge from unmet expectations • REBT is active, directive, educational, problem-focused, and cognitive-focused modality

• Clients learn REBT theory and develop and apply related techniques • Youth are expected to take personal responsibility for problems and mistakes and choose to make changes • Cognitive restructuring allows clients to replace and challenge irrational thoughts with rational ones

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Cognitive Therapy (1 of 3) • Active, structured, problem-focused, and views problems as arising from maladaptive cognitions • Use open-ended questions and collaborative dialogue to engage in youth-guided exploration regarding accuracy of beliefs, cognitions, and interpretations • Value for youth to make discoveries independently or with supportive counselor guidance • Four primary domains of cognition-hierarchical structural organization model – Automatic thoughts – Intermediate beliefs Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Cognitive Therapy (2 of 3) • Four primary domains of cognition-hierarchical structural organization model – Automatic thoughts

– Intermediate beliefs – Core beliefs – Schemas

• Cognitive model of depression posits that individuals frequently interpret events negatively • Cognitive distortions typically focus on oneself, the world and environment, and/or the future (cognitive triad)

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Cognitive Therapy (3 of 3) • Cognitive distortions include: – Dichotomous thinking – Arbitrary inference – Selective abstraction – Overgeneralization – Emotional reasoning – Magnification and minimization – Catastrophizing – Personalization – Labeling or mislabeling

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Mindfulness-Based Therapies • Integrate perspectives on cognitions, emotions, and information processing with awareness, acceptance, attention to the present, non-judgement, non-reactivity, and mindfulness meditation • Two domains of practice: Focused attention, bare attention • Focus is on developing practice of being mindful to increase awareness and nonjudgmental acceptance • Self-compassion, nonstriving, letting go, and equanimity are additional themes of emphasis • Includes DBT, ACT, MBCT, MBSR, metacognitive therapy, and emotional schema therapy Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Mindfulness (1 of 2) • Emerged from ancient Eastern spiritual teachings • Described as “paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally” • Deviate from objective and systematic nature of BT

• Differ from Western and Eurocentric values from which most counseling interventions originate • Do not emphasize use of cognitive change strategies, instead focus is on observation, awareness, and nonjudgement

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Mindfulness (2 of 2) • Five tenets of mindfulness: – Observing inner experiences – Acting with awareness – Nonjudgement of inner experience – Describing or labeling inner experience – Nonreactivity • Decentering (diffusion) is the process of maintaining a degree of separation from inner experiences and recognizing them as processes rather than truth • Metacognition is awareness of thinking processes • Acceptance is willingness to experience psychological events without avoiding or allowing them to impact behavior Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Dialectical Behavior Therapy • Integrative and comprehensive approach to address distresses stemming from borderline personality disorder • Emphasis on emotional regulation and problem solving • Combines CBT approaches with dialectical philosophy, biosocial theory, and mindfulness • Integrates acceptance and cognitive change strategies • Cultivation of “wise mind”—integration of reasonable and emotional mind—to manage distress • DBT is not appropriate for young clients or clients with developmental or intellectual disabilities • Inclusion of parents essential to promote change

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Acceptance and Commitment Therapy • Promotes youth discovery of values and goals, commitment to engage in purposeful and fulfilling activities, and total acceptance of all lived experiences • Does not use cognitive change processes or distress avoidance • Suffering and maladjustment stem from experiential avoidance; goal is to increase acceptance of distress • Use of psychoeducation and metaphors to promote acceptance, nonjudgement, and cognitive diffusion • Foundations in behaviorism and relational frame theory, including verbal processing and nonavoidance • Shift from accepting distressing thoughts to moving toward values and committed actions

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Mindfulness-Based Group Programs • Mindfulness-Based Stress Reduction – Developed to address physiological stress-related symptoms – Emphasizes mind-body integration – Relies on mindfulness meditation and yoga to enhance awareness, balance, and appreciation of the present • Mindfulness-Based Cognitive Therapy – Developed to prevent relapse of major depression – Manualized, 8-week program – Uses cognitive and mindfulness-based interventions to detach from negative thoughts and prevent relapse Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Role of the Counselor in CBT (1 of 2) • Cultivation of warm, accepting relationship is essential • Relational factors are particularly important with CBT, as confrontation and challenging thoughts and promoting tolerance of distressing emotions may be required • Educating clients and families on approaches and techniques ensures understanding of how interventions work • Active, present-focused, educational, and structured processes are typical of traditional CBT approaches • REBT is particularly directive and confrontational • CT requires the use of collaborative empiricism or guided discovery Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Role of the Counselor in CBT (2 of 2) • Use of mindfulness-based and acceptance-based theories requires different roles and responsibilities • Stems from differing views on etiology of suffering and how change occurs

• Environment is typically less structured and focuses on moment-to-moment presence and experience • Attention focuses on acceptance rather than changing cognitions • Mindfulness practice for counselors and with clients possesses many benefits within the therapeutic relationship

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Assessment • Standardized assessment measures can be used to assess thoughts and behaviors • Beck Youth Inventories may be used to assess symptoms of depression, anxiety, self-concept, disruptive behavior, and anger

• Assessment plays a role in most CBT approaches, and assessment focus will vary depending on specific orientation • Beck’s cognitive triad can help with assessment, conceptualization, and treatment planning when using CT

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Traditional CBT Interventions (1 of 2) • Typical structure includes:

– Planning for session and setting agenda with youth – Reviewing previously learned content and skills and processing homework

– Introduce new material, psychoeducation, and practice techniques or skills – Collaborative processing and feedback – Assign homework • Resembles BT processes of changing, shaping, prompting, and fading

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Traditional CBT Interventions (2 of 2) • Individuals with Disabilities Education Act (IDEA) was enacted in 1975 to ensure children with disabilities receive a free public education that meets individual learning needs • Applies to any school that receives federal funding to accommodate youth who have a physical or mental disability • Individualized Education Plans (IEPs) are documents developed for youth who have a disability to describe special education provisions

• Accommodations and provisions of IEPs are regularly reviewed and updated and help youth access the learning environment and content equitably

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A-B-C Model • • • •

Also known as ABBCDEF model Defining element of REBT Allows counselor to dispute irrational beliefs Includes the following elements: – Activating event – Beliefs – Consequences – Disputing irrational beliefs – Effective new thinking – Feeling and behaving in new ways

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Socratic Questioning and Guided Discovery • Techniques used in CT to help youth challenge their own faulty cognitions • Socratic questioning allows youth to explore effect faulty cognitions and perceptions have on behavior or emotions

• Counselors take a curious and “not knowing” stance to pose questions that guide youth to draw own conclusions • Processes minimize power differentials • Less directive and non-confrontational, which may foster trust and rapport, and reduce opposition • Promotes problem-solving skills, reflexivity, metacognitive awareness, and empowering experiences Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Thought Testing and Behavioral Experiments • Thought testing-intervention designed to evaluate validity of thoughts • Collaboration where counselor and youth search for evidence to confirm or refute cognitions • Homework is often assigned to practice thought testing • Behavioral experiments during session or as homework allow youth to collect data to challenge cognitions • Youth engage in behavior or activity and keep track of data regarding findings • These techniques help youth observe influences of thoughts on emotions and behavior Copyright © 2019 Pearson Education, Inc. All Rights Reserved

DBT-Based Interventions • Emotion regulation: identifying, processing, and reducing vulnerability to distress by engaging in pleasant activities, using effective problem-solving skills, and increasing positive emotions • Mindfulness-based skills help youth identify and understand experiences of distress and develop emotional regulation skills • Developing awareness of three different mind states:

– Rational mind – Emotional mind – Wise mind Copyright © 2019 Pearson Education, Inc. All Rights Reserved

DBT-Based Interventions • Promotion of integrating Rational mind and Emotional mind resulting in Wise mind • Use to process behaviors and consider alternatives • Wise mind is cultivated through use of mindfulness practices • Acronym IMPROVE provides distress-tolerance skills: – Imagery – Meaning – Prayer – Relaxation – One thing at a time – Vacation – Encouragement Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Distress Tolerance • Self-soothing skills and distraction skills • Scripts and acronyms help clients remember and use skills • Wise mind ACCEPTS acronym can be used to help manage distress: – Activities – Contributing – Comparisons – Emotions – Pushing Away – Thoughts – Sensations Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Interpersonal Effectiveness • Address factors that promote stable relationships with others • Involve three core domains: objective effectiveness, relationship effectiveness, and self-respect effectiveness • Allow youth to develop skills related to making requests or conveying wants, managing and resolving conflict, establishing and maintaining positive relationships, and maintaining and enhancing self-respect • Acronym DEAR MAN GIVE FAST can be used to help clients learn and practice effective social skills

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Developmentally Appropriate Mindfulness-Based Interventions • Traditional mindfulness practices such as meditation, body scan, or yoga may be too complex for youth • Adaptations to length, structure, and style of mindfulness exercises may be needed based on development • The following are youth-appropriate mindfulness techniques: – Belly-Breathing Friend – Animal Parade – Mystery Bag – Vacation Destination – Letting Go – Everyday Mindfulness Activities Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Family Interventions and Involvement (3 of 4) • Involvement of families is important to reinforce skills and concepts and increase understanding of managing behaviors • Homework assignments are critical in traditional CBT and practice of skills is essential across CBT approaches • Parents can be included when providing psychoeducation

• Promotes ability of parents to reinforce and extend interventions in the home • Systemic and familial factors can be addressed through CBT approaches as well

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Parent and Family Integrated CBT Approaches • Several CBT approaches have been modified for use with families and parents

• Approaches include: – DBT – Coping Cat

– Trauma-focused CBT – Family CBT – MBCT-C

– And MBSR for School-Age Children Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Reality Therapy and Choice Theory • Reality therapy is a didactic, collaborative, and actionoriented approach to changing maladaptive behaviors • Based on choice theory, goal is to change behavior to more effectively meet individual needs and experience more satisfying relationships • Maladaptive behaviors and unhappiness are viewed as the result of unsatisfying relationships and absence of meaningful connections with others • Emphasized role of choice and power clients do have over actions • Central foci are choice and behavior

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Core Concepts and Goals of Counseling (1 of 3) • According to choice theory, behavior is driven by five genetically-encoded basic needs: – Survival – Love and belonging – Power – Freedom – Fun • Needs may vary by the moment based on individual circumstances and perceptions of reality • Love and belonging is considered the most essential need

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Core Concepts and Goals of Counseling (2 of 3) • When needs are unmet, clients experience unhappiness, pain, or loneliness • Individuals may choose maladaptive behaviors to meet needs • All behavior reflects on individuals’ current knowledge and ability to meet needs • Approach is de-pathologizing and contextualizes behavior rather than diagnosing it • Use of psychoeducation to provide adults with information about mental health stigma and negative language • Educating clients to make better choices to better meet unsatisfied needs is central to reality therapy Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Core Concepts and Goals of Counseling (3 of 3) • Quality world includes a picture album of personal wants and subjective perceptions of one’s real identity • Wants are related to basic needs and motivate behavior

• Use of creativity with younger clients may be helpful in conveying these complex concepts to youth • Information collected about clients’ quality world, picture album, and basic wants and needs can be used to inform treatment planning

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Total Behavior (1 of 5) • All human experience can be described as behavior: – Acting – Thinking – Feeling – Physiology • Behaviors are intended to resolve discrepancies between quality world and perceived world • Behavior is presupposed as choice because it comes from within and serves a purpose • Paining behaviors-acting out emotional states to demonstrate youth control over behavior

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Total Behavior (2 of 5) • Youth can control their own behavior, but not others’ behavior • Attempts to control others’ behaviors result in frustration, alienation, and lack of meaningful relationships • Emphasis on personal choice and the impact of behaviors on relationships • Focus on what client can and cannot control • Reality therapy’s emphasis on personal responsibility, adult expectations, and behavioral consequences is well framed to address many youth-oriented problems

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Total Behavior (3 of 5) • Seven deadly habits: – Criticizing – Blaming – Complaining – Nagging – Threatening – Punishing – Bribing or controlling with rewards

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Total Behavior (4 of 5) • Seven caring habits: – Caring – Listening – Supporting – Contributing – Encouraging – Trusting – Negotiating difference

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Total Behavior (5 of 5) • Goal is to replace deadly habits with caring habits to promote positive relationships • Posing the question ‘Are your behaviors helping you get what you want?’ can help gently challenge behavioral choices • Ten axioms of choice theory provide conceptualization of human nature and inform the practice of reality therapy

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Role of the Counselor in Reality Therapy (1 of 2) • Developing and maintaining strong therapeutic alliance is an essential task and prerequisite for client change • ABCDEFG approach can be used to guide interactions: – AB: Always be…

▪ Courteous ▪ Determined ▪ Enthusiastic ▪ Firm ▪ Genuine Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Role of the Counselor in Reality Therapy (2 of 2) • Promoting responsibility and commitment are core foci throughout counseling • Counselors hold clients accountable for choices, expect commitment, and do not accept excuses • Counselors refrain from asserting judgement and refocus toward identifying new plans that are more manageable • Counselors teach clients about personal responsibility, choices, and the importance of meaningful relationships • Self-evaluation is used to help youth assess effectiveness of behaviors • Counselors communicate that change is difficult, using affirmations, and drawing upon client strengths Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Counseling Process and Procedures (1 of 2) • WDEP system is primary delivery method of choice theory that delineates counseling processes in practical and procedural manner • Integration of environment, relationship, and interventions comprise reality therapy’s cycle of counseling • Initial phase involves developing rapport and therapeutic alliance while creating safe, nonjudgmental environment • WDEP System: – W-What do you want (wants, needs, perceptions)?

– D-What are you doing (direction and doing)?

– E-is what you are doing helping you (self-evaluation)?

– P-What is your plan (plan to replace ineffective behavior)?

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Counseling Process and Procedures (2 of 2) • WDEP System: – W-What do you want (wants, needs, perceptions)?

– D-What are you doing (direction and doing)?

– E-is what you are doing helping you (self-evaluation)?

– P-What is your plan (plan to replace ineffective behavior)?

• Processes focus on clarifying goals, increasing motivation, identifying behaviors used to meet needs, evaluating impact of behaviors, and planning for change of ineffective behaviors

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Family Interventions and Involvement (4 of 4) • Family can influence youth’s perceived satisfaction of five basic needs, especially belonging and love • Youth relationships with family will play a role during treatment • Parent Involvement Program applies reality therapy to family counseling—educates family about RT and provides them with avenues for addressing youth behaviors congruent with RT • RT concepts may be integrated into family counseling and family approaches to change, with a focus on enhancing, sustaining, and nurturing systemic relationships

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Copyright This work is protected by United States copyright laws and is provided solely for the use of instructors in teaching their courses and assessing student learning. Dissemination or sale of any part of this work (including on the World Wide Web) will destroy the integrity of the work and is not permitted. The work and materials from it should never be made available to students except by instructors using the accompanying text in their classes. All recipients of this work are expected to abide by these restrictions and to honor the intended pedagogical purposes and the needs of other instructors who rely on these materials.

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Counseling Children and Adolescents First Edition

Chapter 6 Counseling Theories that Focus on Background Experiences and Relationships

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Counseling Theories that Focus on Background Experiences and Relationships (1 of 3) • Psychodynamic theory focuses heavily on past life experiences and their influence on personality and behavior • Presumes early relationships have lifelong impact

• Especially relevant when counseling youth • Emphasis on defense mechanisms, internal, and unconscious conflicts • Counselor facilitates insight and making the unconscious conscious Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Counseling Theories that Focus on Background Experiences and Relationships (2 of 3) • Individual psychology is a strengths-based approach that promotes the idea that youth are constantly striving to become better versions of themselves • Individual psychology celebrates resilience and embraces holistic nature of mental health • Attends to individual in context rather than in isolation and emphasizes therapeutic encouragement • Focuses on past relationships, personal experiences, birth order, lifestyle preferences, individual qualities Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Counseling Theories that Focus on Background Experiences and Relationships (3 of 3) • Person-centered theory—also called client-centered therapy—posits that youth have a natural capacity to resolve their own problems • With the right conditions, youth will move toward achieving their full potential • The therapeutic relationship is the vehicle for change • Maintains optimistic view of human nature, emphasizes the relationship between counselor and client, and allows client to guide counseling Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Psychodynamic Therapy (1 of 2) • Early life experiences are critical to understanding personality and behavior

• Early caregiver attachments are important • Enhancing insight into inner world promotes growth • Attention to awareness of factors that influence, motivate, affect behaviors, thoughts, and feelings • Assumption that symptoms diminish as awareness of internal conflicts become conscious

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Psychodynamic Therapy (2 of 2) • Common factors of psychodynamic approaches: – Therapeutic alliance as corrective experience – Bring unconscious into consciousness – Focus on early life experiences – Internalized unconscious conflicts manifest as symptoms – Thought, feeling, and action are a product of biological and psychological processes – Symptoms have meaning – Transference is essential to facilitating counseling

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Core Concepts and Goals of Counseling (1 of 4) • Four areas of focus: drives, ego, objects, self • Humans have innate and often unconscious drives: sex/life and aggression/death • Drives versus social forces create internal conflict • Conflict is unconscious and source of symptoms • Human nature is deterministic • Three aspects of personality: id, ego, superego • Intersection between conscious and unconscious creates conflicts between personality aspects

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Core Concepts and Goals of Counseling (2 of 4) • Personality forms through psychosexual stages of development:

– Oral stage (birth-18 months) – Anal stage (18 months-3 years) – Phallic stage (3-6 years)

– Latency stage (6-12 years) – Genital stage (12-adulthood) • Fixation may occur if needs/behaviors are exacerbated or frustrated during a particular stage

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Core Concepts and Goals of Counseling (3 of 4) • Consciousness is the awareness of self and world – Includes thoughts, memories, and feelings in awareness that can be reasoned about – Youth become more logical and rational over time as development occurs • Preconscious information is not part of conscious awareness but is accessible if triggered • Unconscious information includes memories, drives, feelings, impulses outside of awareness and often includes unacceptable emotions

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Core Concepts and Goals of Counseling (4 of 4) • Unconscious processes determine and affect behaviors and conscious ideation

• Counselors help youth access unconscious memories, impulses, and drives so impulses do not emerge as dreams or mental health symptoms • Use of dream analysis, free association, and play are used to access unconscious • Counselors help clients balance what they want and what they believe to be right, especially for young children who have not developed superego Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Ego Psychology (1 of 2) • Focus on ego, less emphasis on id or unconscious • Ego functioning is the relationship between id, ego, superego, and outside world • Involves reality testing, impulsivity, object relations, defense mechanism, emotional regulation, self-reflection • Focus on building health ego functioning: mediation of internal and external demands while limiting defenses • Defenses may be emotional, cognitive, or interpersonal and ultimately keep youth from experiencing anxiety • Defense mechanisms (repressive, regressive, tactical) distort/deny reality and are unconscious processes

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Ego Psychology (2 of 2) • Erikson’s psychosocial stages focus on tasks/crises that occur in relation to the external world • Development occurs in social context • Failure to resolve crisis results in impaired functioning • Psychosocial stages include: – Trust vs. mistrust (birth-1 year) – Autonomy vs. shame and doubt (1-3 years) – Initiative vs. guilt (3-6 years) – Industry vs. inferiority (6-11 years) – Identity vs. role confusion (12-18 years)

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Object Relations Theory • Focuses on early self-concept development in the context of relationships with others, especially caregivers • Involves object (others), self, and the relationship • Internal images and schemas are developed based on early relational experiences • Relationships and relational functioning are complex due to the past experiences and subjective interpretations that influence current relationships • Provides opportunities for understanding youth behaviors

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Attachment Theory • Based on the idea that attachment style between youth and parents predicts personality and relational patterns

• Youth are programmed to seek attachment and use attachment to explore their world • Attachment is the responsibility of the caregiver; if the response is appropriate, secure attachment occurs • If caregiver responds in aloof or inconsistent manner, attachment will be avoidant, ambivalent, or disorganized • Disorganized attachment is often the result of trauma

• Counselors should promote parent-child attachment and attunement to promote secure attachment Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Separation-Individuation Theory • Focus on interpersonal processes, specially youth’s ability to establish a sense of separateness from others, especially primary love object (usually the mother) • Focus on development of unique and separate self • Disruptions in separation-individuation process during early childhood could result in poor individual identity later • Youth with unmet needs do not have sense of security needed to separate and individuate • Impact of poor separation-individuation may include inability to differentiate self as unique and develop healthy sense of self throughout the lifespan

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Self-Psychology (1 of 3) • Focus on development of healthy narcissism (sense of self)

• Narcissism is innate and can mature into healthy adult narcissism, which becomes self-love • Self-love precedes one’s ability to love others

• Narcissistic injury result when there are threats to the cohesiveness of self • Sense of self develops in early life in relation to caregivers • Psychopathology is viewed as a disturbance of the self

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Self-Psychology (2 of 3) • Self must be understood in relation to self-objects • Self-object (caregiver) responses to young children inform individual’s identity development and sense of self • Self-objects evolve over time and may include transitional objects and later romantic partners as youth age • Two narcissistic needs are met through self-object relationships: admiration and connection

• Mirroring self-objects who are perceived as admired helps meet this need • Fusion with idealized self-objects helps develop connection Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Self-Psychology (3 of 3) • Early self-object relationships become incorporated into representational world through transmuting internalization • Psychopathology results from incomplete self; nonrelational self-objects is a self-prescribed remedy

• Counselors should use empathy to provide corrective experience and opportunities to develop self • Twinship transference, alter ego transference, and mirror transference all involve youth’s perception that the counselor has special characteristics similar to him or her • Transference, developed through therapeutic alliance, becomes corrective and promotes self-cohesion

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Goals of Psychodynamic Theory (1 of 3) • Help client focus on affect and emotional expression

• Increase acceptance of emotions • Identify recurrent themes and patterns • Explore wishes, desires, and fantasy life

• Focus on and develop adaptive interpersonal relationships • Enhance self-understanding • Replace unconscious defense mechanisms with conscious coping strategies

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Goals of Psychodynamic Theory (2 of 3) • Phases of counseling: – Opening phase: Establish routines, develop therapeutic alliance, assess strengths and needs – Middle phase: Explore patterns, promote youth expression, use transference relationship to understand challenges and facilitate change – Termination phase: Review gains, manage reemerging symptoms, address countertransference, separation, loss, dependency, and create follow-up plans

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Goals of Psychodynamic Theory (3 of 3) • Overall goals include:

– Shaping youth-counselor relationship – Facilitating youth awareness and self-understanding – Working with parents to establish collaborative alliance rooted in neutrality

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Role of the Counselor in Psychodynamic Therapy • Counselors encourage open expression from youth • Purposeful maintenance of neutral presence to foster transference • Transference is the client’s projection of characteristics of another person onto the counselor • Countertransference is transference from counselor to the young person • The counselor and the relationship between counselor and youth are the primary interventions • Observations, play, interactions, and interpretations may also be used Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Psychodynamic Counseling Process • Assessment is typically not formal or structured • Assessment may involve play to explore young person’s development and self-expression • Projective testing may be used to assess unconscious, including house-person-tree and sentence completion test • Assessment process continues throughout counseling process

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Establishment of Rapport and Therapeutic Alliance (1 of 2) • Counselor becomes secure base attachment and may need to become the “good enough” parent in counseling • Ways to strengthen therapeutic alliance include: – Attending to youth and family experiences – Active, affirming, caring style, with reflective support for youth and family

– Facilitate emotional expression – Explore interpersonal themes or conflicts – Making accurate interpretations and increasing insight

– Highlight past and current counseling successes Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Establishment of Rapport and Therapeutic Alliance (2 of 2) • Play is vehicle for exploring and working with younger children, including parallel play and moving between participant and observer during play • Adolescents may be more verbal but still involve action • Parallel play with adolescents may include games • Adolescents may push back against the counselor, which is to be expected and should generally be addressed directly/confronted to facilitate transference

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Client Resistance • Resistance is the blocking of the counseling process and considered an unconscious defense to thwart progress • Can be used to bring unconscious into consciousness • May involve: – Irrelevant or off topic discussion – Silent or minimal responsiveness – Insulting and disrupting comments or disposition – Perseveration – Preoccupation with someone else – Ignoring or not attending to the counselor – Verbosity that is lacking in content Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Transference • Transference occurs once a strong therapeutic relationship is achieved

• Projection of attitudes, motives, and characteristics from other relationships onto the counselor • Youth experience these experiences as authentically real

• Counselor’s goal is to uncover who the youth is projecting onto the counselor and what unconscious or repressed consent is associated with the transference and work through this transference with the client • Counselors should be aware of transference and strive for neutrality and immediacy Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Countertransference • Analysis of countertransference helps the counselor understand youth and themselves in relation to the client

• Involves counselor projection of attitudes, motives, and characteristics from other relationships onto the client • May stem from current or past relationships, or perceptions of self as a child • First sign of countertransference is emotional reaction to the client that is incongruent with presented material • Counselors should explore and reflect on countertransference and engage in ongoing supervision

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Counseling Interventions: Play • Use of play is foundational to using psychodynamic theory with youth to make the unconscious conscious

• Play therapy allows youth to communicate inner world and increases freedom of expression • Facilitates therapeutic alliance and transference

• Promotes socialization • Too much freedom may create anxiety, so adequate structure in play experience should be used • Interpretations of play should be made in thoughtful and well-timed ways

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Catharsis • Self-expression of emotional issues underlying a problem • Environment can promote full range of emotional expression for youth • Emotions may be blocked due to anxiety, shame, fear • Emotions provide important information for counselors

• Providing corrective emotional experiences allow youth to re-experience or transform an unsettled conflict through the use of the therapeutic relationship • Four sequential processes: emotional arousal, emotional experience, emotional expression, emotional processing

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Dream Analysis • Involves recounting latent and manifest content of dreams • May also involve exploration of daydreams • Goal is to explore connection of content to self-concept, internal conflict, ego defense mechanisms, and transference reactions

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Free Association • Youth is encouraged to speak on any topics that come to mind; may employ uninhibited play in younger children • Purpose is to manifest unconscious content through the flow of information being conveyed • Allows counselor to dissect and connect themes • May promote catharsis and release of repressed emotions • Counselors look for discrepancies, omissions, and excesses in content to explore underlying processes

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Interpretations and Insight • Goal is to increase insight and self-understanding • Helps youth to understand something he or she was unaware of previously • Link conscious experience to unconscious defenses, wishes, past experience, or dreams • May be shared by: – Direct observation – Indirect presentation – Using the youth-counselor relationship – Revealing counselor’s perspective

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Family Interventions and Involvement (1 of 4) • Counselors should know and understand family relationships • Parents are a primary source of information and may underscore what happens in counseling • Psychodynamic family therapy may be used to understand and impact family dynamics and promote complementarity • Object-relations family therapy may be used to resolve maladaptive manifestations of early childhood relationships within current relational dynamics

• Parent education can be used to involve family in therapy Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Adlerian Therapy: Individual Psychology • Strength based and emphasizes that individuals are naturally oriented toward growth and change • Mental health problems are viewed as an extension or exaggeration of typical developmental processes • Need for acceptance and contribution • Youth are doing the best they can to improve the world using accessible resources • Counselors help clients harness resources, affirm positive traits, and help clients overcome undesirable drives

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Core Concepts and Goals of Counseling (1 of 2) • Key struggle involves feeling unvalued, incompetent, inadequate, or less acceptable than others (felt minus) • All humans are born with a felt minus and serves as motivator for striving and achieving • Humans are social beings, crave attention and acceptance from others, and want to contribute to society • Inferiority complex represents internalized negative beliefs about self and may be caused by: organic inferiority, overattentive parents, or underattentive parents • Youth behaviors counteract perceived inferiority Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Core Concepts and Goals of Counseling (2 of 2) • Youth work to find behaviors in which they excel to offset feelings of inferiority (perceived plus) • Forward motion and creativity propels attainment of perceived plus • Fictive final goal is a mental schema youth create of the perfect self and strive to approximate this version of self • Lifestyle, or way of being, is informed by fictive final goals – Dominant lifestyle – Getting lifestyle – Avoiding lifestyle – Socially useful lifestyle Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Role of the Counselor in Adlerian Therapy • Therapeutic relationship is essential component of individual psychology • Collaborative process of exploring thoughts, feelings, beliefs, goals, and more helpful ways of interacting with the world • Counselor and client work together to map client’s lifestyle, create insight, and foster change • Counselors should also enlist support from helpful people in the client’s world to promote feelings of connection and contribution

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The Adlerian Therapy Counseling Process (1 of 2) • Counselors use lifestyle assessment to understand client’s social experiences, fictive final goal, perceived plusses, felt minuses, mistaken goals, and inferiority complexes, to inform counseling process • Counselors work to understand mistaken goals that motivate youth behavior and help them develop insight and healthier methods of achieving perceived plus • Mistaken goals include: – Seeking attention – Seeking power – Seeking revenge – Feelings of inadequacy Copyright © 2019 Pearson Education, Inc. All Rights Reserved

The Adlerian Therapy Counseling Process (2 of 2) • Family constellation is the most complex and dynamic aspect of the lifestyle assessment • Birth order influences personal characteristics: – Oldest children – Secondborn children – Middle children – Youngest children – Only children • Birth order does not affect youth in standardized ways and should be considered contextually Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Family Interventions and Involvement (2 of 4) • Social focus of individual psychology is enhanced when involving families in therapy

• Rapport-building with client and family is important • Counselors may use family therapy models rooted in Adlerian therapy as interventions

• Insight for parents and youth help youth meet needs in healthier ways

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Family Interventions and Involvement (3 of 4) • Help parents CARE: – Catch themselves and avoid impulsive action – Assess the goal of the child’s behavior – Respond in empathetic, encouraging ways – Execute responses consistently • Help families respond to youth in ways that help them meet needs in healthy ways • Use logical consequences to help youth learn from actions • Emphasize communication and collaboration between adults in child’s life (family, school, etc.)

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Person-Centered Therapy • Approach that emphasizes the counseling relationship as the necessary and essential vehicle for client change • Non-directive approach that minimizes use of counselorgenerated techniques and interventions • Assessment and diagnosis are avoided, as are making interpretations, giving advice, or setting goals for youth • Optimistic view of human nature • Goal of counseling is to promote self-worth

• Promotes autonomy, acceptance, and efficacy • Child-centered play therapy and person-centered expressive arts therapy are extensions Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Core Concepts and Goals of Counseling • Youth are inherently trustworthy, positive, resourceful and hold potential for constructive change and personal growth • Natural movement away from maladjustment and towards autonomy and self-fulfillment • Counseling is tailored to individual needs of youth • Incongruence between subjective (phenomenological) experience and perceived actualized self causes distress • Exploring this distress ultimately yields congruence, integration, and self-actualization • Nondirective stance, congruence, unconditional positive regard, and accurate empathy are key Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Self-Actualizing Process • Involves development into more fully functioning person with autonomy, self-direction, and congruence • Common attributes of clients engaged in personal growth: – Openness to experience – Trusting one’s self and judgement – Trustworthy behavior – Internal source of evaluation – Creativity • Counselors attempt to promote these qualities through the therapeutic relationship Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Role of the Counselor in PersonCentered Therapy • Counselors maintain dispositions consistent with personcentered philosophy (way of being) • Nurturing, safe, warm, and trusting

• Use of the therapeutic core conditions: – Congruence – Unconditional positive regard

– Accurate empathetic understanding • Core conditions are necessary and sufficient for change

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Person-Centered Therapy Counseling Process • Focus on how they can establish relationship that gives opportunities for youth to become fully functioning • Nondirective process • Counselors are responsible for developing and maintaining strong therapeutic relationship • Use of core conditions throughout counseling process • Use of appropriate self-disclosure and immediacy with therapeutic intention and deliberateness

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Interventions • Instead of techniques, strategies that promote therapeutic relationship are used: – Active listening – Reflection of feelings – Paraphrasing – Immediacy – Open-ended questions or leads

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Family Interventions and Involvement (4 of 4 ) • Approach and fundamental values are congruent with developing positive relationships with families • Child-parent relationship therapy uses person-centered theory to help parents and youth develop warm, nonjudgmental, safe relationship that promotes youth selfesteem • Focus on strengthening parent-child relationships in everyday practice through their way of being and use of person-centered processes

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Copyright

This work is protected by United States copyright laws and is provided solely for the use of instructors in teaching their courses and assessing student learning. Dissemination or sale of any part of this work (including on the World Wide Web) will destroy the integrity of the work and is not permitted. The work and materials from it should never be made available to students except by instructors using the accompanying text in their classes. All recipients of this work are expected to abide by these restrictions and to honor the intended pedagogical purposes and the needs of other instructors who rely on these materials.

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Counseling Children and Adolescents First Edition

Chapter 7 Counseling Theories that Focus on Family Change Processes

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Counseling Theories that Focus on Family Change Processes • Family therapy approaches focus on interactions between all family members • Posit that young people’s problems originate and are maintained in families • Youth cannot make enduring, meaningful change without change in the family system • All family members are responsible for making behavioral changes to support wellbeing

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Family Therapy • Focuses on changing interactions among family members to improve functioning • Involves meeting with youth and family together • Focuses on all family members’ needs rather than singling out youth • Centers on impact interactions have on all family members and how this impacts youth behavior • Presumes youth behaviors are rooted within family and are perpetuated by ongoing interaction patterns

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Core Concepts • Individuals are all interconnected through the family system; what happens to one impacts all

• Identified client (typically the child) experiences problems that reflect problems in family system • Family members must work together to create lasting change

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Reciprocal Influence • Circular causality describes the pattern of interactions in families, where patterns connect and become repeated over time • Dynamics describe family interaction patterns • Promoting appropriate levels of cohesiveness and flexibility helps families and the family members function more optimally

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Functionality in the Family System • Determined by exploring family flexibility related to subsystems and boundaries • Subsystems are smaller systems within the family who have specific ways of relating and interacting • Boundaries in the family may be: – Healthy – Enmeshed – Disengaged • Healthy families are flexible and adapt more easily

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Role of the Counselor in Family Therapy • May be more difficult to build rapport with system • Requires attention to dynamics between counselor, each family member, and system overall to ensure equitable treatment • Exploration of individual perspectives and system dynamics

• More directive role is needed to promote change • Education on family patterns and processes • Promote healthy emotional expression

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Counseling Process (1 of 2) • Counselors must join with family • Entire family is viewed as the client and should be made clear during informed consent process • Explain process, goals, and focus of family therapy • Address how diagnoses will be issued • Explain length, content, and structure of counseling

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Counseling Process (2 of 2) • Assessment typically occurs throughout counseling • Focus on interactional patterns, communication patterns, feedback loops, subsystems, and circular causality patterns • Assessments may also serve as opportunities for identifying and intervening upon family dynamics • Genograms help counselors understanding multiple generations of family patterns/processes

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Family-Based Interventions • Facilitating communication is an essential skill that family counselors promote

• Family counselors work to help families: – Show empathy – Discuss everyday activities

– Attend to children’s needs – Establish family rituals – Increase awareness of verbal and non-verbal interaction patterns

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Facilitating Communication • Includes verbal and nonverbal interactions • Helps families address conflict • Ineffective communication patterns increase conflict, decrease intimacy, and reduce problem solving skills • Ineffective communication is unclear, indirect, distorted, inappropriate, or inaccurate • Goal is have clear, direct, and explicit communication patterns • Counselor actively works to change patterns

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Promoting Insight • Increasing awareness of family dynamics helps family members view patterns and promote change

• Involves making the implicit explicit • Counselors may point out observations and patterns of interacting • Circular questioning allows family members to become more aware of dynamics and perspectives

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Reframing Challenges or Difficulties • Reframing involves helping individuals reinterpret events or perspectives in a new way

• Involves validating perspective, providing alternate perspective, and assessing for agreement • Assumes a more positive or neutral function of the behavior or of the individual • Helps to offer new conceptualizations of family members and patterns

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Addressing Disengagement and Enmeshment • Boundaries are unwritten rules of how members differentiate themselves • Differentiation involves separating intellectual and emotional functioning from those of the family • Fusion-too much togetherness • Enmeshment involves inappropriate, boundary- violating closeness

• Disengagement involves too much distance

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Altering Feedback Loops • Families have an inherent drive to maintain homeostasis, or balance • Disrupting homeostasis requires changing family dynamics and processes • Negative feedback loops reinforce return to homeostasis • Positive feedback loops promote change • Both homeostasis and changing homeostasis may be helpful or unhelpful depending on processes involved as a result of the homeostasis

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Assigning Directives and Outside-ofSession Assignments • Family counselors direct family members to engage in new behavior patterns • Indirect directives involve directives families likely won’t follow to promote spontaneous responses • Use of behavioral experiments to change patterns • Paradoxical injunctions appear on the surface to oppose counseling goals, but serve to motivate changes in behaviors and patterns

• Pretend directive involves prescribing the symptom

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Copyright

This work is protected by United States copyright laws and is provided solely for the use of instructors in teaching their courses and assessing student learning. Dissemination or sale of any part of this work (including on the World Wide Web) will destroy the integrity of the work and is not permitted. The work and materials from it should never be made available to students except by instructors using the accompanying text in their classes. All recipients of this work are expected to abide by these restrictions and to honor the intended pedagogical purposes and the needs of other instructors who rely on these materials.

Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Counseling Children and Adolescents First Edition

Chapter 8 The Use of Play and Creative Arts in Counseling

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The Use of Play and Creative Arts in Counseling • Imagination, play, and creativity are essential when counseling youth • May be especially useful for clients with limited verbal skills • Effective in addressing wide range of issues

• May be used with other theories/interventions

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Specialized Certification and Registration • Play therapy is a process where natural play behaviors are used to support change • Art therapy is a process that uses media to explore self, emotions, and experiences to promote change • Play therapists and art therapists have specialized training, certifications, and/or licenses • Counselors may use play and art in their counseling but should refrain from using these terms without specialized training

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Play Therapy and the Use of Play in Counseling • Most often used with youth but may be used with clients of all ages • Play therapy uses intentional processes to promote therapeutic play; this is different from regular play

• Can be used to address a multitude of presenting concerns

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Play Therapy: The Setting • Especially useful in school settings, but can be used in a wide variety of counseling settings • In schools, counselors should help youth transition from play back to class • Maintain designated spaces for play materials • Select materials that are varied, appropriate, culturally sensitive, and adaptable to a variety of presenting concerns

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Foundations of Play Therapy (1 of 2) • Therapeutic play has existed since the early 1900s • Initially a psychoanalytic technique for free association with youth • Most theories were adapted for use with youth through play • Play supports therapeutic relationship • Provides opportunities for catharsis

• Provides metaphors that can be applied to real life • Inherently culturally sensitive

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Foundations of Play Therapy (2 of 2) • Counselors should clearly explain roles and processes to client and family • Parents can be involved in play therapy as active participants or observers with debriefing • Play therapy techniques should be chosen based on client’s individual needs in alignment with counseling theories

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Techniques and Interventions (1 of 2) • Session length may vary depending on youth development, presenting concerns, and theory • Boundary setting involves communicating length and location of play, how aggression will be handled, and how the session will end

– Acknowledge – Communicate – Target alternatives

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Techniques and Interventions (2 of 2) • Decisions about clean up should be made and communicated to client • Counselor may be directive or nondirective • Most counselors use verbal tracking to narrate youth’s play behaviors and identify emotions • Verbal tracking may also be used to identify themes and to facilitate problem solving

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Nondirective Play Modalities • Rooted in belief that youth already possess knowledge, strength, and resources to overcome struggles and achieve goals • Counselor’s job is to provide resources, safety, and space to facilitate play

• No need for interpretation or understanding meaning • Focus on therapeutic relationship and safe space

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Child-Centered Play Therapy • Child-centered play therapy involves empathy, congruence, and unconditional positive regard • Counselor joins client in the process • Process is highly collaborative with few rules • No play behaviors are right or wrong; nonjudgement is encouraged • Client is in control, demonstrated through reflecting rather than giving position • Youth have full autonomy, helping them to identify true values and needs

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Experiential Play • Presumes youth have innate capacity to be well • Youth intuitively reenact past unresolved events • Counselor provides limited direction but does reflect and track underlying meaning of play • Stages include: – Exploratory stage – Testing stage – Dependency stage – Therapeutic growth stage

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Filial Therapy • Rooted in child-centered play therapy • Primary attachment figures (parents) are viewed as change agents and play a key role in therapy • Parents are taught about play techniques and how play benefits youth • Parents are taught how to respond to child • Promotes attachment, relationships, and self-concept development • Counselor serves as coach for parents rather than interacting with youth

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Directive Play Modalities • More authoritative counselor role • Carefully chosen activities and instructions

• Especially useful when time is limited

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Adlerian Play Therapy • Begin with lifestyle assessment • Counselor works to understand client and themes in play behaviors • Play is used to understand the client and promote healthier thoughts, feelings, and behaviors • Underlying meanings of play: – Attention – Power – Revenge – Escape

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Cognitive-Behavioral Play Therapy • Young people’s thoughts directly contribute to feelings, which contributes to mood and behavior • Play is used to promote healthy thinking

• Involves education on cognitive behavioral model • Play may be used to model this process • Play helps counselor explore thoughts, feelings, and behaviors with client and identify more adaptive ways of thinking

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Release Play • Presumes play behaviors mimic real experiences • Youth experience and release emotions through therapeutic play • Youth process and resolve many issues through play, but some may be too difficult to overcome on their own • Counselor intentionally creates metaphorical situations that mimic a real situation for the client • Counselor helps client play and work through emotional reactions to promote catharsis/coping

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Theraplay • Used to foster healthy attachment • Counselors work to promote parent-child attachment and enhance self-esteem/self-efficacy • Three phases: – Beginning-exploration – Middle-challenge and teaching – End-termination • Parents are encouraged throughout the process to replicate play at home and coached on directive process and how to implement in the home

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Sandplay • May be used as a supplement to directive or nondirective play modalities • Youth create miniature replication of their world in sand or similar material • Youth place small toys in the sand and explores his/her world through metaphor • Assess client fit with sandplay due to tactile nature • Counselor serves as a witness to the process • Counselor may take directive or nondirective role

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Creative Arts in Counseling • Engage imagination and senses • Connect with youth in ways that may not be possible in talk therapy

• Creates bridge between logical and creative brain • Process of art is creative in itself • May also be used as a vehicle for theoretical-based interventions • May be integrated with many theories and approaches toward counseling

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Foundations of Creative Arts in Counseling • Creativity is a foundation of counseling • Intentional choice of activities is important • Counselor should explore client’s world, culture, development, and presenting concerns before selecting and providing creative interventions • Interventions should address client concerns in developmentally and culturally appropriate ways

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Creative Techniques and Interventions • Art, both two- and three-dimensional, can be used to counsel youth • Especially useful with youth who have limited verbal emotional expression • Music creation can be used to support self-expression and explore client’s emotions • Pre-existing music may also be used as a therapeutic tool, selected by client or counselor

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Writing and Storytelling (1 of 2) • Writing and storytelling can take many forms • Promotes client self-expression

• Can help youth resolve conflict, increase emotional awareness, and promote coping • Journaling allows clients to explore and track thoughts and feelings • Therapeutic storytelling promotes movement through metaphor and fantasy • Counselors may also provide written texts to clients based on specific needs

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Writing and Storytelling (2 of 2) • Drama can be used to promote self-expression • Psychodrama allows individuals to act out life events that feel unfinished or still linger • Scripts and performances can be based on real-life or contain metaphors • May be used in individual or group format

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Copyright

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Counseling Children and Adolescents First Edition

Chapter 9 Conceptualizing Young Clients’ Situations and Directing Counseling

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Where to Begin (1 of 2) • Focusing and directing counseling may be challenging given client’s layered and complex circumstances and concerns • Theories and models should be used to direct assessment process • I CAN START model is a comprehensive, strengthsbased treatment planning model • Setting will determine level of detail involved in treatment planning

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Where to Begin (2 of 2) • Take a relational, collaborative, strength-based approach with clients • Focus on evidence-based counseling approaches and interventions

• Consider context and culture • Follow the Golden Thread-diagnosis, goals, objectives, and interventions should be in alignment • Be flexible: Treatment plans are not static

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A Conceptual Framework for Case Conceptualization and Treatment Planning • • • • • • • • •

Individual Contextual assessment Assessment and diagnosis Necessary level of care Strengths Treatment approach Aim and objectives of counseling Research-based interventions Therapeutic support services Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Individual • Counselors should consider who they are as they approach each client • Consider who the counselor is as an individual and how his or her personal and professional qualities and factors relate to work with a given client • Professional characteristics include theoretical approach, interventions, pacing/structure, demeanor and style, and approach to engaging families and community partners

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Contextual Assessment (1 of 3) • Assessment of interrelated contexts: intrapersonal, interpersonal, and macro-level • Intrapersonal context includes: – Developmental considerations – Emotions or feelings – Attachment – Personality – Behaviors or actions – Biology or organic context – Cognitions or thinking

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Contextual Assessment (2 of 3) • Interpersonal context involves the client’s environmental circumstance and the impact it has on growth and development • Ecological systems theory suggests five environmental factors that affect development: – Microsystem – Mesosystem – Exosystem – Macrosystem – Chronosystem

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Contextual Assessment (3 of 3) • Macro-level context includes demographics: – Age – Gender – Race – Ethnicity – Socioeconomic status – Sexual orientation – Disability/ability – Religious preferences/spirituality – Geographic location

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Assessment and Diagnosis (1 of 3) • Assessment process informs counselor about client’s presenting concerns, experiences, needs, and impact of counseling • Used to inform DSM-5 diagnosis • Informs case conceptualization and treatment planning processes

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Assessment and Diagnosis (2 of 3) • Assessment data includes: – Identifying information – Description of the presenting issues – History of the presenting issues – Medical history – Past counseling experiences – Family history – Personal history – Mental status exam data – Referrals or other diagnostic considerations

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Assessment and Diagnosis (3 of 3) • Mental status exam includes assessment of: – Appearance – Behaviors/psychomotor activity – Attitudes – Affect and mood – Memory and intelligence – Reliability, judgement, insight – Speech and thought – Perceptual disturbances – Orientation and consciousness

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Necessary Level of Care (1 of 2) • Level of care includes setting and intensity of counseling services • Clients should be placed in least restrictive level of care that is appropriate for their concerns • Consideration of treatment settings, types of treatment, and pacing of treatment • Continuum of care involves ongoing assessment of client needs and adjustment of level of care based on client progress, concerns, and needs

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Necessary Level of Care (2 of 2) • Factors to consider: – Symptom severity, diagnoses, and prognosis – Physical limitations or medical conditions – Suicidal ideation – Ability to care for oneself – Past treatment settings and client response – Aims and goals of treatment – Social and community supports and resources – Desired level of care of client/family

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Strengths • Assessment of client strengths • Discussed in detail throughout the text

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Treatment Approach • Theory or model of counseling selected

• Directs selection of evidence-based interventions • Also based on counselor training, client preferences, practice setting, and other factors • Guidelines exist for evaluating approaches • Counselors should also consider client/family factors, counselor factors, and other treatment variables when selecting interventions

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Aim and Objectives of Counseling (1 of 2) • Rooted in client goals, counselor’s conceptualization of client, theory, and evidence-based interventions • Should be well defined, with objectives stated in measurable, behavioral terms • Simple counseling goals are usually best • Counselors should be realistic regarding expectations of change • Consideration of assessment and measurement of client change during goal/objective setting

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Aim and Objectives of Counseling (2 of 2) • S.M.A.R.T. model for developing objectives: – Specific – Measurable – Attainable – Results oriented – Timely

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Research-Based Interventions • Treatments and interventions should have empirical support with specific client concerns for which they are being used

• Interventions inform aims and objectives, which may inform further interventions • Also informed by treatment/theoretical approach • Consideration of client’s situation, development, context, and client/family preferences

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Therapeutic Support Services • Complement to counseling interventions

• May involve education, skills training, socialization, or support groups • Need and type depend on severity of symptoms, nature of setting, diagnosis, strengths, and more

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Copyright

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Counseling Children and Adolescents First Edition

Chapter 10 Youth Suicide, Self-Injury, and Homicide

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Youth Suicide, Self-Injury, and Homicide • Counselors should always make safety considerations a top priority • Counselors have ethical and legal obligations to do so • Integrating safety into counseling emphasizes the importance of safety, helps keep clients safe, and helps protect counselors from legal liability

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Suicide • Suicide is the third leading cause of death in adolescents, leading to 20% of teen deaths annually • Clients seen in counseling are at greater risk • Young and impulsive clients are especially vulnerable • Youth who consider or attempt suicide are attempting to avoid pain, gain control over helplessness, or communicate the only way they can • Counselors must help clients manage strong negative emotions, exert control in their lives, and communicate needs

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Counselor Considerations (1 of 4) • Counselors may feel anxious regarding the possibility of client suicide • It is important to have knowledge and skills needed to respond to a crisis • Counselors should be aware of ethical and legal considerations when working with suicidal youth • Safety measures should be documented clearly • All counselors should have at least one suicide assessment, one decision-making model, and one safety planning model for use with clients

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Client Characteristics (1 of 3) • Suicidal behavior results from interaction between individual and environmental factors • While some demographics possess increased risk, these cannot be used to predict which clients will experience suicide • Additional biological, psychological, social, and family factors exist that increase client risk • Sexual orientation and gender identity is a particularly important element to consider

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Assessment (1 of 5) • Potential suicide risk should be assessed: – At intake/initial counseling session – Any time suicidal ideation arises or is suspected – Sudden change in affect or behavior – At the time of discharge

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Assessment (2 of 5) • When assessing suicide risk, counselors should consider the following: – Presence of psychiatric symptoms – Past suicidal behavior – SES and family factors – Exposure and access to means – Recent negative life events • Also consider the use of a self-report screening • The acronym SAD PERSONS can be used as a guide to assessment

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Assessment (3 of 5) • Signs of acute risk include verbalized threats to harm or kill oneself, actively seeking means to do so, and talking or writing about suicide or death • In these cases, further assessment and potential psychiatric intervention are necessary, including contacting emergency personnel • Counselors should be persistent when assessing risk, as clients may conceal true feelings • Ample time needs to be allotted to process suicidal ideations or risk, so waiting until the end of session should be avoided

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Safety Plans and Intervention (1 of 2) • Parents should be involved as collaborative partners in the process • No-suicide contracts carry benefits and limitations; an alternative to these contracts is the Commitment to Counseling Statement • Determining the level of care is the most important element of effective intervention • Decision trees may be used to determine appropriate level of care

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Safety Plans and Intervention (2 of 2) • Safety plans are intended to enhance clients’ adaptive, life-sustaining behaviors • Should include: – Triggers and warning signs – Ways for clients to manage these signs – Designated social support network – Steps to take should the thoughts escalate – Internal and external protective resources • Safety plan should be typed/written and provided to client and family

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Suicide Intervention/Prevention and the Schools • School staff play an important role in assessing and addressing risk • School counselors also play an important role, although little research currently addresses this • School-based suicide prevention and intervention programs is essential • School counselors can also collaborate with students and families following a suicide attempt

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Nonsuicidal Self-Injury • Is “the intentional destruction of one’s body tissue without suicidal intent and for purposes not socially sanctioned” • Rates vary widely depending on youth population

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Counselor Considerations (2 of 4) • May cause intimidation, worry, or frustration in counselors • Counselors should assess reactions and methods and consult throughout the counseling process • Self-injury and suicidality do not always co-occur, however counselor should be sensitive to and address possible suicidal ideation in clients • Use of relational, active, dynamic, and change-focused approaches may benefit clients

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Client Characteristics (2 of 3) • There is no single profile of a young person who selfinjures • Some client factors may increase risk of self-injury • Self-injury can function as a: – Form of affect regulation – Method to influence others by communicating emotions that cannot be verbalized – Means of decreasing feelings of isolation – Means of self-stimulation

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Assessment (4 of 5) • Complex nature of self-injury may make it difficult for counselor to conceptualize client needs • Assess frequency, duration, severity, and onset of selfinjury as well as antecedents, functions, consequences and dynamics of the behavior • Ongoing medical assessment/evaluation may be necessary for some clients • Assessment of safety should consider context and purpose of self-injury related to suicidality

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Intervention (1 of 2) • Behavior and cognitive-behavior therapy are currently supported by research • Dialectical behavior therapy is an approach that shows promise for treating self-injury • Problem-solving therapy is a type of CBT that may be useful with clients who self-injure • Behavior management strategies may be effective • Motivational interviewing may be used to enhance client motivation to change

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Homicide • Violence, especially among young men, is a serious concern • Most violence is aimed at peers • Homicide is the second-leading cause of death among youth age 15-24

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Counselor Considerations (3 of 4) • Counselors must remain open to discussing and assessing for risk despite possible discomfort • Counselors should self-monitor verbal and nonverbal responses to communicate neutrality • Regular consultation and supervision are recommended when working with this population • School staff and counselors should be prepared to address violence in schools • Prevention strategies should be integrated into schools as well

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Counselor Considerations (4 of 4) • Counselors should facilitate safety and document steps they have taken • Understanding of homicide risk factors is essential • Knowledge of safety planning model and approach for working with youth who are homicidal • Safety measures should be explicitly integrated into treatment plan • Awareness of community resources and settings for clients who have increased risk are necessary

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Client Characteristics (3 of 3) • No single personality profile exists, however clusters of personality traits have been identified • Increased risk may stem from personality, environmental, psychological, and/or family-based factors • Counselors should be aware of factors that increase risk in youth

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Assessment (5 of 5) • Clinical judgment should be used to decide if assessment is needed • Ask in clear, direct manner if client intends to harm another person, if a plan exists, the method of the plan, and if they have access to means • If client poses safety risk to counselor, session should be held in a safe environment • SIMPLE STEPS mnemonic can be used to assess risk of homicidal behavior

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Intervention (2 of 2) • Counselors should work with parents and limit client’s access to weapons • Client may need more restrictive level of care if risk of harm is great • Helping clients develop coping skills and identifying alternatives to violence may be helpful • Strengthening social supports is also needed • Crisis cards with warning signs, coping skills, and plan of action can be provided • Safety plans should also be created

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Copyright

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Counseling Children and Adolescents First Edition

Chapter 11 Family-Related Transitions and Struggles

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The Nature of Family-Related Transitions and Struggles in Youth • The “traditional family” is less prevalent now than ever before • Parents who are directly involved and exhibit positive attitudes to children have children who adjust and cope more effectively • Family-related transitions and struggles may increase risk factors for youth

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Divorce/Parental Separation (1 of 4) • About half of all marriages end in divorce • Divorce may impact a child immediately, in a delayed fashion, or not in any perceivable way • Many youth struggle with circumstances that occur around or following divorce • Some youth will respond through: – A normal reaction to crisis – Age-specific exaggerations – Emerging psychopathology – Psychosomatic symptoms

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Divorce/Parental Separation (2 of 4) • Age, gender, SES, and post-divorce parental conflict all influence youth response to divorce • Substance use may be a particular concern with some youth before, during, or after the divorce • Parental conflict may be a stressor for youth and is the single biggest predictor of negative outcomes • Quantity and quality of parent-child interactions can serve as a protective factor

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Divorce/Parental Separation (3 of 4) • Six psychological tasks show how youth progress through divorce experience: – Recognizing/acknowledging what is occurring – Identifying and reducing parental conflict and maintaining friendships and activities – Resolving the loss – Resolving intense emotions – Accepting lived situation – Achieving hope for future relationships

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Divorce/Parental Separation (4 of 4) • Counselors should attend to their own reactions and countertransference regarding divorce • Focus on positive parenting interventions may be helpful for youth • Prevention programs may also encourage coping • Prevention often occurs in a group setting and provides education, support, and coping skills

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Step and Blended Families (1 of 2) • Approximately 1/3 of youth under age 18 will live in a stepfamily at some point during childhood • Generally, youth who live with a stepparent do not fare as well as youth living with two biological parents • Involves renegotiation of family dynamics that may be confusing, frustrating, and inconsistent • Adults must take proactive measures to ensure successful transition

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Step and Blended Families (2 of 2) • Most common presenting concerns are communication and parenting difficulties • Some stepfamilies have difficulty managing boundaries and maintaining clear parental roles • Families should use clear communication throughout transition process to ease tension and challenges • Counselors can facilitate relationships during session with activities that foster connection/communication • Parenting skills can also be developed through counseling process

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Kinship Caregivers (1 of 2) • In some communities and populations, individuals who are not biological parents but who are family members may be primary caregivers • Youth may be placed with kinship caregivers for a variety of reasons • Placement with grandparents is especially common • Consideration of legal issues related to custody should be made and communicated with family

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Kinship Caregivers (2 of 2) • Families are typically involved with multiple legal and community agencies • Presence/absence of siblings in the home may also be a source of stress • Likelihood of trauma and limited resources may further increase risks and challenges • Holistic method of supporting kinship caregivers is needed to support caregiver and family • Attention should be paid to issues stemming from cause for placement and reactions to placement

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Adoption (1 of 2) • On average, 120,000 youth are adopted each year • Youth have little power in the adoption process • Counselors should empower these youth during the counseling process • Closed adoptions do not allow for contact or information regarding biological parents to be shared • Open adoptions allow for some degree of contact • Adoptions may be domestic or international • Parent-child attachment requires work, but not all families require counseling to manage this process

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Adoption (2 of 2) • Counseling should be considered in cases where youth show signs of distress, there is a history of trauma, learning-related struggles exist, attachment issues arise, or mental health symptoms emerge • Youth may experience identity issues and will possess extra layers regarding identity formation • Adolescents may have curiosity regarding birth parents and seeking connection • Essential tasks involve facilitating attachment and attunement between parent and child

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Parental Substance Abuse (1 of 2) • It is estimated that 8 million youth under age 18 live with an adult with a substance use disorder • Substance use may impact whether physical and/or emotional needs are met • Maternal substance use can also impact the child in the womb • Growing up with a parent who has substance-related problems increases risk for a variety of concerns • Academic performance, social relationships, wellness, and behavior may be negatively impacted

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Parental Substance Abuse (2 of 2) • Counseling should balance educational, psychological, and behavioral interventions • Parents’ substance use must be treated or referred • Counselors may be family-focused, child-focused, or a blended approach of the two • Approaches should be developmentally appropriate and promote coping, insight, and functioning as appropriate for the setting and situation • Feelings of guilt and shame are common and should be explored and addressed

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Grief, Loss, and Bereavement (1 of 3) • Many children experience death and loss of a grandparent, parent, sibling, or pet • Some children may struggle with this loss • Stage model of grief and loss includes feelings of: – Denial – Anger – Bargaining – Sorrow – Acceptance • Current models view grief as non-linear process

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Grief, Loss, and Bereavement (2 of 3) • Youth ideally will move to integrated acceptance relative to the loss • Children’s developmental level influences their views of death and loss • Symptoms may meet diagnostic criteria for a mental disorder in some youth • Childhood traumatic grief may emerge, especially when the loss is traumatic or witnessed by the youth • Cultural and religious factors should also be considered when working with loss in youth

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Grief, Loss, and Bereavement (3 of 3) • CBT is an effective intervention • Grief psychoeducation is also important to normalize feelings and reactions to loss • Youth should be encouraged to tell their story in their own words (grief and loss narrative) to develop tolerance for and integration of experience • Some youth may have ambivalence about the loss and should also be addressed • Preserving positive memories may also be helpful • Exploring changes stemming from loss is important

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Copyright

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Counseling Children and Adolescents First Edition

Chapter 12 Academic and Social/Emotional Transitions and Struggles

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Time Management Difficulties • Time management difficulties may emerge for a variety of reasons: – Lack of organizational or planning skills – Poor emotional regulation – Potential mental health symptom (e.g., ADHD) • Cognitive, behavioral, and solution-focused interventions may be especially helpful • Practicing skills, establishing routines, and involving family in process are important

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Study Skills Deficits • May be a result of poor time management and/or deficits in information processing, recall, critical thinking, and/or vocabulary • Counselors should first understand specific difficulties experienced by youth • Counseling involves balancing education, practice, support, and referrals as appropriate • Consideration of specific anxiety around testing should be made if overall performance is adequate but test performance is poor

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Test Anxiety • Test anxiety is specific to the school setting, is situational, and occurs specifically in relation to tests • May manifest in various ways • Cognitive-behavioral strategies are useful and should be combined with education about test anxiety • Interventions should focus on awareness of onset/precursors, normalizing experience, developing coping skills, and externalizing test anxiety • Assessment of external stressors that influence symptoms should be ongoing

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School Attendance Problems • Excessive absenteeism can suggest emotional or behavioral difficulties and can have long-term negative consequences on wellbeing • May manifest as school refusal or truancy • Interventions for both include addressing underlying mental health concerns • School refusal interventions should involve family and other stakeholder support • Truancy interventions may require multi-systemic interventions and supports

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Changing Schools • All youth will experience school transitions • Some youth will experience additional school transitions as well • Normative transitions include shifts that all students in a grade or school navigate • Nonnormative school transitions involve school changes outside of the typical transition periods

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Normative School Transitions (1 of 2) • Sources of stress include uncertainty regarding school culture, rules, teachers, building layout, and class structure • Increased need for self-discipline, time management, and social changes may also be stressors • Transitions may also be exciting and empowering • Counselors should support preparation for transitions from home to preschool/kindergarten, kindergarten to elementary school, elementary to middle school, middle to high school, and high school to college

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Normative School Transitions (2 of 2) • Counselors should help normalize feelings of excitement and happiness mixed with depression or anxiety in youth during transitions • Parents can help prepare youth in the home with rules, routines, and expectations likely to exist in school setting • Counselors should help client and family proactively prepare for transitions throughout school years • Support after transition can also be helpful to ease transition and address difficulties

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Nonnormative School Transitions • May occur due to family relocation, change in family structure, or opportunity to attend new school • May be especially challenging for youth because they typically occur in isolation and involve move to new school or district with new peers, teachers, and staff • May experience positive benefits as well • Counselors can help youth learn about new school to prepare for transition, practice social skills, and help youth grieve loss of current school

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Difficulty Making and Maintaining Friendships (1 of 2) • Social competence is a key component to making and keeping friendships • Lack of social competence often leads to rejection • Cliques often form around shared interests, and dyadic friendships form within the clique • Youth tend to associate with peers who share similar physical characteristics, struggles, hobbies • Counselors can educate teachers, staff, parents, youth about the importance of social development

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Difficulty Making and Maintaining Friendships (2 of 2) • Counselors should holistically assess youth with friendship concerns for other issues that may be interfering with friendship development • Counselors can teach social skills to youth who lack social competence

• May occur in individual or group settings • Promoting positive self-concept in youth also supports friendship development

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Bullying (1 of 5) • Involves one person intentionally causing physical or emotional harm to another • May occur in person or online • Bullying may be used to express and displace uncomfortable emotions onto others • May also occur when lack of order and supervision exists in the home, community, or school • Selection of victim is often based on physical size, timidness, and/or physical or cognitive difficulties

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Bullying (2 of 5) • Victims may also bully others in response to bullying • Peers may join in with bullying despite disagreeing with it to maintain social status • Adults should intervene immediately and provide support to bullies, victims, and bystanders • Proactive approaches are effective and appropriate especially in school setting • Anti-bullying programs exist and are typically used in the school setting • Character development programs may also help

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Bullying (3 of 5) • Goals for victims include: – Increasing problem-based and emotion-based coping skills – Increasing self-defense strategies – Increasing connections with allies – Promoting less predictable behaviors to bullying – Teaching assertiveness skills – Teaching how, when, and where to seek support

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Bullying (4 of 5) • Goals for bullies include: – Holding youth accountable – Developing relationships with bullies – Providing experiences to promote acceptance of others – Teaching empathy skills

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Bullying (5 of 5) • Goals for bystanders include: – Teaching methods for recognizing and acting on feelings of discomfort – Staying calm and demonstrating casual disapproval of bullying – Telling the person to stop – Gathering more people to the scene – Stopping actions that don’t work and trying something different – Getting help – Methods for supporting bullies and victims

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Sexual Orientation Struggles (1 of 4) • Sex-youth’s biological reproductive functioning • Gender-emotional manifestations of biological sex • Some youth’s thoughts, feelings, and behaviors do not align with their biological sex • Gender-nonconforming youth accept biological sex but do not behave in gender-conforming ways • Transgender youth do not accept their biological sex and experience the world through the viewpoint of the opposite sex and gender

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Sexual Orientation Struggles (2 of 4) • Ongoing assessment is important, as development of gender self-perception is an ongoing process • Sexuality typically develops around puberty and can be explored once a counselor understands youth’s gender self-perceptions • Acronyms and terms exist to identify and describe the varied lived experiences of this population • Discrimination may occur in the home, neighborhood, school, community, or work, and can negatively impact functioning and feelings of safety/belonging

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Sexual Orientation Struggles (3 of 4) • Counselors can promote acceptance of others and help youth find appropriate, healthy ways to explore and express sexuality • Counselors can also harness resources and ensure sexuality is one part of holistic youth identity • Counselors working with this population should regularly access supervision and possibly counseling to promote ongoing professional development • Mental health research has historically pathologized LGBTQ individuals; this should be validated alongside helping clients explore their identities

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Sexual Orientation Struggles (4 of 4) • Youth may experience discrimination from religious institutions, which may impact family relationships • Focus of counseling is reducing or eliminating environmental factors that threaten healthy development and increasing factors that support positive identity development • School counselors can advocate for LGBTQ youth • Individual counseling can focus on coping skills, healthy sexual practices, and identity development

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Intimacy and Dating (1 of 2) • Youth typically begin to explore romantic intimacy during adolescence • Interactions and observations in childhood contributed to youth dating experiences • Sexuality adds a layer of complexity to the process • Unreciprocated love, breakups, and previous experiences of abuse may cause difficulties • Romantic difficulties increase risk of academic, emotional, social, and family difficulties

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Intimacy and Dating (2 of 2) • Sexual education can be provided schoolwide, in small groups, or individually • May be a controversial subject for some, so parental consent is important • Counselors can help clients: – Develop a healthy sense of self – Explore observed relationship models – Set boundaries and expectations for relationships – Address past trauma and abuse – Develop emotional regulation, communication, and coping

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Intimate Partner Violence (1 of 3) • IPV is an important consideration for youth involved in romantic relationships • May manifest through physical violence, sexual violence, stalking and/or psychological aggression • May be a single incident or ongoing struggle • Many youth do not report IPV to anyone and remain in unhealthy relationships for extended periods • Risk factors include observing IPV in the home, high stress levels, and high levels of anger; high anxiety and neighborhood violence are also risks for girls

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Intimate Partner Violence (2 of 3) • Prosocial beliefs and parental monitoring are protective factors • Counselors should promote safety as the foundation by assessing immediate safety and developing safety plans with youth • Assessment of legal and ethical considerations related to parental involvement is necessary • Counselors should consider making referrals for medical services for physical concerns

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Intimate Partner Violence (3 of 3) • Interventions should be individually tailored • Interventions should promote safety, self-esteem, selfefficacy and mental health symptom management • Encourage development of healthy support networks and re-engaging in enjoyable activities • Trauma-focused CBT and Seeking Safety are two interventions with empirical support • Seeking Safety addresses co-occurring trauma and substance use disorders • Prevention programs also exist for IPV

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Copyright

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Counseling Children and Adolescents First Edition

Chapter 13 Neurodevelopmental and Intellectual Impairments

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Neurodevelopmental and Intellectual Impairments • Failure to meet developmental milestones impacts youth’s adaptive functioning • Disruption in developmental processes impacts cognitive functioning in some capacity • Youth who have adaptive functioning deficits struggle at school, home, and in the community • Parents with children who have developmental deficits present with fears and concerns for the child’s future • Counselors can be instrumental in supporting parents and youth

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Attention-Deficit/Hyperactivity Disorder • Characterized by difficulties with attention • Includes approximately 5% of school-age children • Three types: – Predominantly inattentive type – Predominantly hyperactive/impulsive type – Combined type • Symptom onset before 7 years old • Oscillation between inattention and hyperfocus • Impulsivity involves acting without considering consequences; hyperactivity is excessive movement

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Counselor Considerations (1 of 6) • Struggles associated with ADHD may impact peer relationships and academic performance • May have difficulties with sitting still, focusing, time management, and boredom, which has implications for counseling process and setting • Counselors should select creative, multidiscipline, multifaceted approaches to engage youth • Parent training and understanding of family dynamics are important components of counseling • Active engagement of parents and youth are crucial

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Assessment of ADHD • Information from parents, teachers, schools, mental health professionals and youth is needed • Cultural sensitivity is important, as behaviors may be perceived differently in different cultural contexts • Standardized assessment measures for ADHD exist • ADHD has a high degree of comorbidity with oppositional defiant disorders, learning disorders, anxiety, depression, substance use, conduct, and intermittent explosive disorders • Medical evaluation should be considered as well

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Counseling Interventions (1 of 7) • Should target all relevant settings • Pull together multiple people and systems • CBT combined with medication management has most significant impact on reducing ADHD symptoms • Focus on symptom management, behavior change, parent training, and school collaboration/consultation • Neurofeedback may be effective for use with teens • Attend to organizational skills, problem solving, metacognition, and emotional reactivity • Strength-based focus identifies strengths and skills

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Counseling Interventions (2 of 7) • Parent education and training focuses on helping parents identify triggers and circumstances that perpetuate or increase symptoms • Train parents in behavioral interventions, use of verbal feedback, consistency, and rule enforcement • Education around ADHD symptoms, reinforcement of positive behaviors, positive parenting, token economy systems, time-out use, and planning for future behaviors is also helpful for parents • Medications (stimulant and non-stimulant) may be used to manage ADHD symptoms

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Autism Spectrum Disorder • Genetic and environmental risk factors exist • Youth who have autism experience significant deficits in socialization and communication skills • Presence of restricted and/or repetitive interests and behaviors • Limitations in cognitive and adaptive functioning • Wide variation in presentation and symptoms • Approximately 1% of the youth population has ASD

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Counselor Considerations (2 of 6) • Early identification and intervention is crucial • Signs that may indicate a child has autism include: – Not meeting typical developmental milestones – Limited eye contact – Restricted social interactions – Limited language development • Counselors should look for communication patterns underlying observable behaviors

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Counselor Considerations (3 of 6) • Youth may also experience sensory processing issues and emotional dysregulation • Parenting a child with autism may be challenging and parental and sibling support may be especially useful • Balance between changing environment and changing behaviors • Youth may use augmented and alternative communication devices, which will impact counseling

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Counselor Considerations (4 of 6) • Goals for youth may include – Addressing sensory processing issues – Increasing communication – Altering socially-inappropriate behaviors – Increasing social skills and relationships – Increasing adaptive functioning

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Assessment of Autism Spectrum Disorder • Thorough clinical interviews that consider: – Developmental milestones – History of abnormal behavior – Three-generation family history – Medical history – Mental health treatments and effectiveness • Standard interview protocols and behavioral observation instruments are effective in assessment • Consider possibility of co-occurring mental disorders

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Counseling Interventions (3 of 7) • Should focus on addressing specific symptoms and increasing adaptive functioning • Applied behavioral analysis (ABA) combined with social skills training and supplemental therapies and parent training is considered most effective • ABA is used to change behavior by breaking it down into smaller parts and using reinforcement schedules to increase or extinguish behavior • ABA may be delivered in individual, group, or family/home settings

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Floortime • • • •

Often used in conjunction with ABA Developmental, relational, play-based approach Adult joins child in developmentally-appropriate play Adult can direct/redirect the child toward increasingly complex interactions, thus increasing complexity of communication techniques/processes • Promotes interest in the world, communication, social engagement, and emotion identification • Parental counseling/emotional support is needed

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Intellectual Disabilities • Characterized by below average general intelligence (IQ score at/below 70) • Continuum of severity (mild, moderate, severe, and profound) • Limitations are most pronounced in academic and problem-solving situations

• Influenced by genes and environment • More males, more African Americans, and more low-S ES youth are diagnosed

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Counselor Considerations (5 of 6) • Diagnostic criteria includes IQ score two standard deviations below the mean and impairment in adaptive functioning • Adaptive functioning domains include conceptual skills, social skills, and practical life skills • Thorough clinical assessment in conjunction with standardized intelligence assessment is necessary

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Assessment of Intellectual Disabilities • Assess adaptive functioning along with IQ score • Educational interventions for at-risk youth may be effective in mitigating symptoms and severity • Some youth may warrant non-verbal assessment • Consideration of co-occurring disorders is needed

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Counseling Interventions (4 of 7) • Early identification and intervention is important • Approaches vary depending on severity of disability and level of adaptive functioning • Behavioral approaches may help youth with moderate to severe impairment, and integrated approaches may help youth with mild impairment • Behavior therapy and CBT have demonstrated efficacy with this population • Family involvement is crucial to help translate skills into the home, school, and community

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Counseling Interventions (5 of 7) • Case management is essential • Use of visual schedules, token economies, and other positive reinforcement forms may be useful • Providing concrete visual models/information regarding counseling concepts can be helpful • Modeling can be used to promote skill development • Medication may be used to address specific behavioral or emotional conditions associated with their intellectual disability, typically combined with behavioral therapy

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Specific Learning Disorders • Involves discrepancy between intellectual ability and specific area of academic achievement

• Discrepancy reflects significant difference between expected performance and actual performance • Many youth fail to be identified and develop ineffective skills for managing these impairments • Affect approximately 5-15% of youth • Reading disorder is most common • Learning disability is a legal term; specific learning disorder is the diagnostic term

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Counselor Considerations (6 of 6) • Difficulties with learning fundamental academic skills to be successful in academic settings, including: – Reading and fluency – Reading comprehension – Spelling – Written expression – Arithmetic calculations – Mathematical reasoning • Most youth experience consistent progression of initial failure, doubt, lower self-worth, and decreased effort in future academic tasks that require the skill

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Assessment of Learning Disorders • Often occurs by school psychologists, using data from teachers, school counselors, observations, youth response to interventions, standardized tests, and complete history • Standardized measures are useful in diagnosis • Disorders often co-occur with other neurological disorders involving emotional or behavioral problems • Counselors must assess for and differentiate between learning disorders and other disorders

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Counseling Interventions (6 of 7) • Addressed in general education setting through special education accommodations • Individualized education program (IEP) or 504 plan may be used to describe specific accommodations • Counseling interventions often focus on increasing academic achievement and competence • Often involves short-term, goal-focused counseling • Counselors may also advocate for clients • Consultation and collaboration with school and families is essential

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Counseling Interventions (7 of 7) • Goals for counseling often include: – Psychoeducation about the disorder – Overcoming sense of failure – Facilitating positive attitude toward school – Increasing adaptive coping skills – Using and enhancing social skills – Learning academic strategies • Expressive arts, role play, and therapeutic games may be integrated to promote goal attainment

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Copyright

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Counseling Children and Adolescents First Edition

Chapter 14 Disruptive Behavior Problems

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Disruptive Behavior Problems • Include a wide range of harmful or unhelpful behaviors toward self, others, or property • Some behavior problems are developmentally appropriate; others may reflect subthreshold behavior problems • Intervention can be effective and generally target parents, family members, and youth

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Nature of Disruptive Behavior Problems in Youth • Develop over time; influenced by genes, biology, family and cultural factors, environment, and learning • Cultural considerations must be made during assessment process • Youth often lack insight into underlying motivation • Behaviors typically help youth meet immediate needs • Long-term harmful or negative consequences do not influence behaviors

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Description of Disruptive Behavior Problems • Tend to cluster around conflicts with authority, destruction of property and theft, and/or aggression toward self, others, or animals • Typically progress over time if not addressed • Sensitivity to context is important when diagnosing problem behaviors

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DSM-5 Disorders Associated with Disruptive Behavior Problems • • • • • • • •

Oppositional defiant disorder Conduct disorder Intermittent explosive disorder Pyromania Kleptomania ODD may progress to CD if not addressed Prevalence rates for these disorders is 19% Males are more often diagnosed than females

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Oppositional Defiant Disorder • Characterized by pattern of noncompliance involving anger, irritability, and vindictiveness • Symptoms usually begin in early childhood • Found in up to 3% of youth • Youth are highly emotional and experience high levels of interpersonal conflict at least once/week • Often intentionally annoy others, shirk responsibility, and blame problems on others • Must create significant impairment for diagnosis

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Conduct Disorder • Similar to, but more severe than, symptoms of ODD • Diagnosed in up to 4% of youth • Symptoms typically emerge in middle childhood or adolescence • Youth with CD repeatedly and blatantly violate basic rights of others and violate major social norms • Act with aggression and cruelty toward people, animals, or property • Violation of social norms that carries serious potential for consequences

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Differential Diagnoses • Consider alternative or co-occurring diagnoses that may be relevant or more appropriate, including: – Neurodevelopmental disorders – Anxiety or depression – Stress and trauma – Physical discomfort

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Assessment of Disruptive Behavior Problems • May use specific assessment tools • Consider co-occurring disorders and differential diagnoses during assessment • Refer for physical to rule out medical causes • Consider developmental history, demographics, and risk factors • Use of diagnostic interview and standardized assessments can provide a more complete picture

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Integrated Treatment Components • Development of strong therapeutic relationship is essential for working with these disorders • Stakes can be high when working with this population, so use of best practices is essential • Counseling is most helpful with family engagement • Behavioral and emotional regulation interventions, problem-solving skills training, dialectical behavioral therapy, multisystemic therapy, and family interventions should all be considered

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Behavioral Interventions • Classical and operant conditioning can be used to understand, target, and change behaviors • Steps include: – Understanding motivation for behavior – Remove reinforcing consequences for behavior – Reinforce desirable behaviors – Practice in session, help teachers and other adults implement behavioral interventions, track behavior • May also integrate affective and cognitive domains

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Mindfulness-Based Skills • Affective awareness—the ability to recognize and control emotions—is essential to counseling this population • Many disruptive behaviors are rooted in effective emotional expression processes • Promote connection between feelings and behaviors • Mindfulness techniques can be used to increase awareness in the present moment • Breathing exercises can be taught to youth • Session may begin/end with mindfulness practice

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Cognitive Structuring Abilities • Thoughts, feelings, and behaviors are intertwined • Identification of maladaptive thoughts is essential • Cognitive restructuring, through the use of CBT, can help youth identify and change cognitions • Socratic questioning is used to promote insight • Psychoeducation on Cognitive Triad can help youth track and identify connections between thought, feeling, and behavior • Counselors help clients identify and change triggers, thoughts, feelings, actions, and consequences

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Problem-Solving Skills Training (1 of 2) • CBT approach that helps youth restructure cognitive processes at the heart of problem behaviors • Highly structured intervention • Introduce steps to problem solving: – What am I supposed to do?

– What else can I do?

– What will happen if I do this?

– What choice should I make?

– How did I do?

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Problem-Solving Skills Training (2 of 2) • Initially, counselor will explain and process each step with youth • Youth practice application to problems in session through talk therapy and role play • Games and scenarios may also be used • Especially relevant in residential treatment settings • Operant conditioning may also be used to promote problem solving

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Dialectical Behavior Therapy • May be used preventatively with subthreshold behavioral problems or as an intervention for youth with diagnosable concerns

• Use of DBT to help clients identify triggers, develop emotional regulation skills, and overcome barriers to implementing skills • Affective education can help youth understand behaviors and seek healthier emotional relief • Key stakeholders may be integrated into process

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Integrating Family • Counselors should educate family regarding potential sources of behavioral problems • Provide information on level of care and type of support needed from family and social supports • Parents are a source of information, support for translating practices into the home, and resource for monitoring behaviors • Counselors should work to involve family members whenever possible

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Parent Management Training (1 of 2) • PMT is a program that provides clear, effective, targeted strategy for family behavior change • Highly structured, manualized approach • Includes assessments and worksheets as well • Goals of PMT include: – Increase parents’ ability to communicate rules and expectations – Increase youth understanding of consequences Increase parental focus on positive reinforcement – Build on youth successes

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Parent Management Training (2 of 2) • Parents are educated on motivations for misbehavior • Parents are asked to attend to youth behaviors • Encouragement of new reinforcement patterns to promote desired behaviors • Implementation of token economy system if reinforcement is not sufficient • Anticipation of problematic situations and provision of clear rules and consequences to discourage misbehavior

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Multisystemic Therapy • MST is a comprehensive approach for addressing serious behavior problems • Blends CBT, family therapy, and community psychology foundations • Primary caregivers seen as most influential element of the change process • Focus on harnessing resources in multiple settings to work toward nine key principles

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Multisystemic Therapy: Key Principles (1 of 2) • • • • •

Identify function of each behavior problem Focus on strengths and protective factors Encourage and develop responsible behaviors Create concrete, measurable goals and objectives Identify and alter home, school, and community interactions that support behavior problems

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Multisystemic Therapy: Key Principles (2 of 2) • Implement developmentally-appropriate interventions that support academic, career, and personal-social growth and change • Implement interventions that require daily or weekly family participation • Regularly assess readiness to change and progress • Provide primary caregivers with tools to generalize interventions so long-term behavior change can be maintained across settings

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MST Assessment • Occurs in the home after initial referral • Counselor visits home, school, and anywhere youth spends considerable amounts of time • Family and other stakeholders identify desired outcomes of counseling • Provider develops goals, explores functions of behaviors in the family, and identifies smaller goals stemming from overall goals • Use of evidence-based interventions to reduce risk factors and harness strengths to promote change

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Psychopharmacotherapy • Medication is not commonly supported, although comorbid disorders may be treated with medication • Some medications may target specific symptoms • Medications sometimes used include mood stabilizers, antidepressants, stimulants, SNRIs, and antipsychotics • May be helpful to provide quick relief from symptoms and bring youth to baseline so they can fully participate in interventions

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Copyright

This work is protected by United States copyright laws and is provided solely for the use of instructors in teaching their courses and assessing student learning. Dissemination or sale of any part of this work (including on the World Wide Web) will destroy the integrity of the work and is not permitted. The work and materials from it should never be made available to students except by instructors using the accompanying text in their classes. All recipients of this work are expected to abide by these restrictions and to honor the intended pedagogical purposes and the needs of other instructors who rely on these materials.

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Counseling Children and Adolescents First Edition

Chapter 15 Abuse and Trauma

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Abuse and Trauma • Over half of youth will experience one or more traumatic events in their lifetime • Understanding of trauma-informed practices is essential for counselors • Trauma- and stressor-related disorders are identified in the DSM-5 • Not all youth who experience trauma will have long-term symptoms, but all youth with trauma history benefit from counseling to process and integrate experiences

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Nature of Abuse and Trauma-Related Difficulties in Youth (1 of 3) • Trauma is not a reaction, but an event, specifically, “Exposure to actual or threatened death, serious injury, or sexual violence” • May involve direct experience, witnessing, learning about an event that happened to someone close to youth, or repeated exposure to details of trauma • Type 1 includes single-incident traumas • Type 2 includes ongoing, chronic, complex trauma • Variability exists in responses to trauma, but type 2 traumas typically produce poorer prognoses

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Nature of Abuse and Trauma-Related Difficulties in Youth (2 of 3) • Emotional responses may include anxiety, terror, guilt, shock, irritability, hostility, depression • May experience difficulty concentrating, confusion, selfblame, intrusive thoughts, lower self-efficacy, fear losing control, and fear recurrence of traumatic event • Response to trauma is highly dependent on situation and context of youth • Trauma impacts brain development, emotional regulation, self-concept, attachment, feeling safe in relationships, behavior control, and physical health

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Nature of Abuse and Trauma-Related Difficulties in Youth (3 of 3) • May shift self-regulatory processes toward survival • Many youth display resilience and adaptability, ultimately returning to previous level of functioning • Only a minority of youth are diagnosed with PTSD • Counselors help identify/enhance protective factors • Reactions to trauma depend on developmental stage • Violent trauma may increase risk of conduct or substancerelated difficulty • Revictimization may influence coping and victimization of others

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Types of Abuse and Trauma-Related Difficulties • Youth maltreatment includes abuse and/or neglect • Counselors are mandated to report such instances and must be aware of state laws and procedures • Counseling youth who experience maltreatment may create complex emotions within counselors • Intentional monitoring and supervision are essential

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Child Abuse • Early detection and treatment are the most effective approach for preventing long-term consequences • Defined as action or inaction that results in emotional, physical, or sexual harm of youth and includes: – Physical abuse – Sexual abuse – Emotional abuse • May be perpetrated by adults or by peers, both of which can carry long-term consequences and poor adjustment across domains

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Physical Abuse • • • •

Includes non-accidental injury of youth Observable effects are often visible to counselor Parents/caregivers may struggle to explain injuries May demand that youth conceal injuries and delay medical care • May have history of violent interactions with youth and may rationalize behaviors • Youth may be overly fearful, aggressive, or withdrawn and depressed • Signs and symptoms exist in both youth and parents

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Sexual Abuse (1 of 2) • Occurs when a person forces or exposes a youth to sexual activities for the person’s own purposes • 1 in 4 girls and 1 in 5 boys will be exposed to sexual abuse during childhood in the U.S. • Sexual abuse that occurs alongside intimidation and physical abuse significantly increases risk of severe mental health disorders in the future • Physical symptoms often involve focus on genitals

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Sexual Abuse (2 of 2) • Behavioral symptoms include: – Excessive sexual knowledge or behaviors – Difficulties with sleep including nightmares, bedwetting, sleep disturbance, fear of bedtime – Excessive masturbation – Acting out behaviors to regulate strong emotions – Withdrawal, depression, or anxiety • Majority of youth will not disclose or will retract claims of sexual abuse due to feeling helpless, trapped, pressure of secrecy, or poor responses to disclosure • Signs and symptoms exist in both youth and parents

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Emotional Abuse • Psychological abuse that affects self-worth and emotional development • More difficult to detect and address • May include, but is not limited to: – Rejecting – Ignoring – Humiliating – Intimidating – Isolating – Corrupting • Signs and symptoms exist in both youth and parents

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Child Neglect • Neglect includes lack of supervision, provision, affection, and support needed to meet needs and is the most prevalent form of youth maltreatment • Includes the following: – Physical neglect – Emotional neglect – Medical neglect – Educational neglect • Signs and symptoms exist in both youth and parents

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Adult Partner Violence in the Home • Exposure to IPV is associated with higher rates of abuse/neglect and increases risk across domains

• Often occur along parental substance use, unemployment and financial stress • High intelligence, positive coping skills, and access to community and social supports promote resilience • Youth may display emotional, physical, social, and behavioral symptoms • Instability of caregivers and risk of violence toward youth necessitate attention to safety and stability • Knowledge of resources for IPV victims and requirements for mandated reporting is needed Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Mass Violence, Terror, or Disaster (1 of 2) • Include natural and human-made disasters • Disrupt youth perceptions of the world, sense of safety, and sense of social order

• Exposure via mass media may also impact youth • May contribute to emotional distress, susceptibility to mental illness, developmental delays • Early-life trauma may influence worldview and identity development process • Reactions may be diverse and complicated by losses experienced during the event

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Mass Violence, Terror, or Disaster (2 of 2) • Social support moderates relationship between this type of trauma and development of PTSD • Social support may promote adaptive coping skills, reduced risk-taking behaviors, feelings of self-worth, reduced risk of loneliness, and ability to understand experience in context • Counselors who work with victims of trauma must be vigilant for signs of vicarious trauma and seek regular supervision, ongoing education, and counseling to manage stress and risk of vicarious trauma

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Trauma-Related Disorders • Includes: – Reactive attachment disorder – Disinhibited social engagement disorder – PTSD – Acute stress disorder – Complex trauma

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Reactive Attachment Disorder and Disinhibited Social Engagement Disorder • Disorders are a byproduct of attachment problems • RAD is characterized by inhibited and emotionally withdrawn behaviors regardless of situation or stress • DSED is characterized by disinhibition and emotional intrusiveness in interactions with unfamiliar adults • Behaviors are attempts to meet basic needs • Abused and neglected youth are at serious risk • Context and resilience factors influence development/nondevelopment of these disorders Copyright © 2019 Pearson Education, Inc. All Rights Reserved

PTSD and Acute Stress Disorder • Primary DSM-5 diagnoses associated with trauma • PTSD is characterized by: – Re-experiencing the traumatic event – Avoidance symptoms – Increase in emotional arousal/activity • Youth frequently experience a range of symptoms associated with experiencing the trauma • Youth under age 6 may present unique symptoms • Untreated symptoms may result in ongoing heightened responses and/or dissociation

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Complex Trauma (1 of 2) • Involves continuous, pervasive trauma • Often associated with sever child abuse or multiple exposure to trauma beginning in early childhood • Different from PTSD, and impacts: – Ability to regulate affect – Ability to process information and focus – Self-concept – Impulse and self-control – Forming and maintaining relationships – Biological processes

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Complex Trauma (2 of 2) • Symptoms may include: – Cognitive distortions related to helplessness, worthlessness, hopelessness – Identity disturbances, boundary issues, and lack of self-awareness – Interpersonal and affect regulation difficulties – Dissociation – Substance use – Somatization – Non-suicidal self injury and suicidal ideation

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Assessment of Abuse and TraumaRelated Difficulties (1 of 2) • Clinical interviews allow for assessment of immediate safety, trauma history, and effects of trauma on level of functioning • First concern is assessing immediate safety and, if immediate danger is present, counselors must collaborate with other professionals/agencies • Assess onset, frequency, duration, and severity of past trauma exposure • Include parents with care and understanding of limitations of parental information, especially when parental abuse/neglect is suspected Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Assessment of Abuse and TraumaRelated Difficulties (2 of 2) • Use of trauma-related assessments and checklists increases reliability of assessment and diagnosis • Symptoms should be assessed relative to youth developmental level • Attention to pre-existing functioning and trauma reactions is important as symptoms can change over time • Remain aware of potential co-morbid diagnoses that may be rooted in traumatic experience

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Counseling Interventions (1 of 2) • Trauma-informed counseling should focus on establishing safety, appropriate processing of traumatic experience, social reconnection, and orientation to more positive future • Family should be involved as appropriate • Focus on resilience, development, and enhancing functioning in addition to symptom management

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Counseling Interventions (2 of 2) • Consider approaches that: – Promote safety – Incorporate psychoeducation – Enhance distress reduction and affect regulation – Facilitate emotional processing – Implement cognitive interventions – Enhance youth identity – Increase family involvement and relational functioning

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Promoting Safety (1 of 2) • Despite assumptions, many youth involved with children’s services are returned to, or remain in, potentially unsafe environments • Promoting safety includes helping clients feel safety: – Related to re-experiencing trauma symptoms – In their day-to-day physical environment – From recurring traumatic events

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Promoting Safety (2 of 2) • Strategies to promote safety include: – Teaching grounding techniques – Consistent structure for counseling sessions – Discussing safe and unsafe behaviors – Develop safety plan • Safety planning allows youth to take active approach and may increase feelings of safety

• Encourages awareness of triggers, unhelpful behaviors, self-initiated techniques to promote safety

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Incorporating Psychoeducation • Promotes understanding, accurate information, and validation and normalization of experiences • Necessary throughout counseling process • Involves education on prevalence, misconceptions, reasons for perpetration, immediate and lasting reactions/responses, reframing, and safety planning related to abuse and trauma • Needs to be individualized and integrated as appropriate throughout the counseling process

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Enhancing Distress Reduction and Affect Regulation Skills (1 of 2) • Focuses on managing arousal and combating sustained anxiety and hyperarousal • Major components include: – Relaxation training – Identification and countering of thoughts and emotions – Becoming aware of and managing triggers and response to triggers

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Enhancing Distress Reduction and Affect Regulation Skills (2 of 2) • Use of questions can help youth manage strong emotions that arise: – Personal change questions – Accepting questions – Letting go questions

• Identification and management of triggers can be combined with grounding techniques to manage response to triggers that leads to disconnection from counseling session

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Facilitating Emotional Processing (1 of 4) • Involves intentionally and therapeutically exposing youth to environmental triggers to help them manage negative emotions and rescript negative cognitions • As exposure increases, desensitization increases • Promotes separation of present thoughts and feelings from painful trauma thoughts and feelings • Creation of trauma narrative is essential • Includes youth’s written description of experience • Value in strategy surrounding creation of trauma narrative and exposure to triggers

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Facilitating Emotional Processing (2 of 4) • Developing the trauma narrative allows youth to develop healthier coping and emotion regulation • Desensitizes youth to thoughts, feelings, and triggers • Allows open discussion of experiences and confrontation of remaining triggers • Sharing narratives with themselves and family members is associated with positive outcomes • Encourages integration of experiences and identity creation in context

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Facilitating Emotional Processing (3 of 4) • Creating a trauma narrative is a complex process that involves youth sharing what they think is important about traumatic experience • Grounding techniques should be established prior • Counselor facilitates in-depth exploration in client’s own words, increasing descriptiveness over time • Appropriate pacing and sensitivity are necessary • Counselors moderate intensity to promote therapeutic process and avoid re-traumatization

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Facilitating Emotional Processing (4 of 4) • Expressive techniques may be used to construct and explore trauma narrative • Scaling questions may be used to monitor intensity • Family involvement is important, especially related to sharing the trauma narrative as a therapeutic act • Sharing the narrative may produce anxiety in youth and family members • Parent sessions prepare parents for this process

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Implementing Cognitive Interventions • Youth may experience shift in perceptions of themselves, the world, and their place in the world • Cognitive interventions allow counselor to help client identify, challenge, and replace unhelpful thoughts • Cognitive distortions frequently emerge in discussing the traumatic event or trauma narrative • Counselor attempts to identify and clarify underlying beliefs and disputing maladaptive cognitions • Cognitive restructuring, rehearsal, social reinforcement, and role plays may also be used

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Enhancing Identity (1 of 2) • Trauma may adversely impact youth identity and selfperceptions • Youth may fail to develop the ability to assess needs, maintain positive sense of self when experiencing strong emotions, and predict reactions • Youth may enter self-preservation state and become hyperalert • Introspection and self-exploration—required to develop sense of self—are not a priority when danger may reappear at any moment

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Enhancing Identity (2 of 2) • Counselors must create a sense of safety for youth • Self-exploration is encouraged by encouraging youth to focus on internal experiences, discover their own thoughts, and explore likes/dislikes, view of self and others, and the counseling relationship • Youth may be invited to write a letter to their perpetrator when appropriate to promote identity development and resilience • Attention should also be paid to developing healthy interpersonal relationships

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Increasing Family Involvement (1 of 2) • Family members can play a critical role in supporting youth • Allows for monitoring of symptoms, use of coping skills, and check-ins to provide progress updates • Attention should be paid to parents’ feelings and reactions regarding their child’s experiences • Educating parents is important, especially when unresolved trauma in parents complicates coping • Referrals may be made to help parents cope with their own trauma experiences

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Increasing Family Involvement (2 of 2) • Sometimes parents are the cause of trauma • Generally, reunification is the overarching goal • Enhancing parenting skills and ability to manage youth behaviors may be protective against further abuse or trauma • Counselors in these situations should increase parental engagement in counseling and focus on communication, safety, and parenting skills

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Specific Trauma-Focused and Disaster Intervention Approaches (1 of 2) • Considerable research exists on treatment approaches, including: • Trauma-Focused Cognitive Behavioral Therapy • Cognitive Behavioral Intervention for Trauma in Schools • Combined Parent-Child Cognitive Behavioral Therapy • Eye Movement Desensitization and Reprocessing • Trauma Focused Integrated Play Therapy • Psychological First Aid

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Specific Trauma-Focused and Disaster Intervention Approaches (2 of 2) • SSRIs are approved for use with adults who are diagnosed with PTSD, however evidence for use with youth is limited • Recommendations generally indicate TF-CBT as first line intervention • Medication may be considered if symptoms are severe or intensify, or if youth experience comorbid mental health disorders

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Copyright

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Counseling Children and Adolescents First Edition

Chapter 16 Substance Abuse

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Substance Abuse • Substance use among young people creates difficulties for parents, schools, medical and mental health professionals, and youth • Approximately 5% of youth met criteria for a substance use disorder in 2014 • Counselors play an important role in prevention and early intervention of substance use

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Nature of Substance Use Disorders in Youth • Substance use disorders are characterized by substance use that continues despite significant substance-related problems and consequences • Recreational use may develop into a substance use disorder over time, especially if:

– Substances are used to cope with emotions – Frequency and quantity of use increases – Biological and psychological factors increase risk

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Risk Factors • Biological family members with a SUD • Poor emotional coping

• History of trauma • Other mental health disorders • Peer influences

• Lack of social skills and poor social supports • Social rejection

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Etiology (1 of 3) • Not all youth with risk factors develop SUDs, and not all SUDs affect youth with risk factors • Biological actions of substances affect and alter brain’s reward systems and perpetuate use through intensely rewarding neurochemical release • Physical and psychological discomfort (withdrawal) may be experienced after stopping substance use when regular use has occurred

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Etiology (2 of 3) • Psychological explanations also exist related to substance abuse

• Negative affective states during transition from childhood to adolescence may increase risk • Use may help youth cope with anxiety, stress, or depression in the short-term despite long-term negative consequences

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Etiology (3 of 3) • Social factors may also influence development of substance use disorders, as peer networks are especially important to youth • Social ties may increase exposure to opportunities for substance use

• Decrease in parental supervision as youth progress through adolescence may increase risk • Experimentation in social situations may progress to substance use disorders in some youth

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Developmental Considerations (1 of 3) • Substance use affects entire biological system

• Youth’s brains are still developing and prioritize immediate rewards over future potential risks • Youth may have low physiological tolerance for substances, and lack of knowledge related to routes of administration may increase risk of harm • Increased risk of side-effects due to smaller size • Substance use may also negatively affect physical development and maturation

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Developmental Considerations (2 of 3) • Substance use may impact short- and long-term psychological functioning • Youth vulnerability stems in part from incomplete brain development

• Emergence of mental health disorders typically overlaps with age when substance use may begin • Substance use may exacerbate underlying mental health symptoms or may be used to manage symptoms of the disorder

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Developmental Considerations (3 of 3) • Substance use can impact family, peer, and romantic relationships, with family concern often serving as a motivation for treatment • Peer associations may change to support use and may increase risk of criminal justice involvement • Social consequences are influenced and complicated by legal responsibility of parents for youth • Family tension may stem from effort and attention paid to manage and treat youth substance use • Social status and reputation may be impacted • Academic functioning may also be impacted

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Development of Substance Use Disorders (1 of 3) • Youth may possess biological and psychological predispositions, including: – Personal and family history of substance use – Mental heath symptoms – Emotional regulation patterns – Response to stress • Youth may lack awareness of risks and develop increasing frequency and tolerance of use over time • With regular use, youth may experience withdrawal symptoms and become physically ill when not using

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Development of Substance Use Disorders (2 of 3) • Peer groups play an important role in development and may influence decisions to experiment • Social acceptance and rejection may both increase risk depending on peer-group norms and accessibility of substance • Substance use may be ubiquitous or accepted in peer groups, making nonuse difficult • Social perceptions related to use may conceal dangers associated with substance use

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Development of Substance Use Disorders (3 of 3) • Developmental processes from childhood to adolescence increases risk-taking behaviors and emotional lability • Youth’s brains do not accurately assess or predict risk of future consequences • These factors may increase risk of substance use • Under the influence, youth’s inhibitions may be further decreased and may lead to increased risk • Lack of immediate consequences may provide false sense of security and inaccurate perception of risk

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Long-Term Effects of Substance Misuse (1 of 2) • Biological consequences include impacts on brain development leading to emotional lability, decreased selfregulation, and inability to delay gratification and consider consequences • Physical growth and maturation may also be affected • Communicable diseases may be contracted with some routes of administration • Death is a possible outcome of use, especially in excessive doses • Physical safety and risks should be described by counselors who work with substance use in youth Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Long-Term Effects of Substance Misuse (2 of 2) • Substance use may affect short-term memory, executive functioning, and assessment of risk • Academic performance may be hindered, which may impact future opportunities and pursuits

• Involvement in the criminal justice system resulting from substance use can further limit opportunities

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Classification of Substance Use Disorders • DSM-5 classifies substance use disorders based on the specific substance and severity of symptoms • Symptoms may be mild, moderate, or severe

• Broadly address four domains: Impaired control, social impairment, risky use, and pharmacological indicators • Requires presence of at least two symptoms over a 12month period • Also includes substance-related disorders including intoxication, withdrawal, and substance-induced disorders

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Assessment of Substance Use Disorders • Assessment typically begins with substance use screening

• If in-depth assessments are indicated by the screen, interviews, standardized assessment instruments, and collateral data collection may be used • Overall goal is to determine degree of risk, appropriate level of care, and types of interventions indicated • Assessment and ongoing monitoring of potential cooccurring mental health disorders is essential

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Assessing Needed Levels of Care (1 of 2) • ASAM level of care assessment and determination should include assessment of the following: – Intoxication or withdrawal risk – Biomedical conditions and complications – Emotional, behavioral, or cognitive conditions – Readiness to change – Relapse, continued use, or continued problem potential – Recovery and living environment

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Assessing Needed Levels of Care (2 of 2) • Levels of care include: – Outpatient treatment – Intensive outpatient treatment – Partial hospitalization treatment – Residential treatment – Inpatient treatment

• Level of care should provide appropriate services indicated in the least restrictive care environment

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Legal and Ethical Considerations • 42 CFR and HIPAA may offer conflicting guidance regarding access of parents to minor substance use records • 42 CFR, a federal law protecting substance use treatment records from release without client consent, requires that minors give written consent to release substance use treatment records • Consultation and supervision in situations where youth refuse to authorize release of records to parents is essential

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Counseling Interventions: Developmental Considerations • Development across physical, affective, and social domains should be considered when selecting treatments and level of care

• Generally, increased structure and support coupled with consistency, tangible rewards for progress, and small achievable, manageable goals and target behaviors work well for youth with a SUD • Inclusion of family to promote similar processes in the home and address impacts of substance use on the family may also be helpful

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Family Involvement and Support • Families impacted by youth substance use may experience fear, anger, and frustration • Concerns regarding financial and legal consequences may also exist • As a result, entire family system warrants attention and support, whether or not the youth engages in treatment for a substance use disorder

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Prognosis • Prognosis largely depends on interventions provided and degree to which high-risk substance use is stopped • Early intervention can help youth who possess risk factors reduce likelihood of developing a SUD • Treatment can be effective, especially when it is initiated early and involves support of family, peers, schools, and communities

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Integrated Treatment Components • Elements and recommendations should be made based on client readiness for change, culture, strengths and needs, and severity of consequences and symptoms • Treatment components may also be influenced by mandates or requirements of agencies such as criminal justice, school, or social services • Consultation, coordination of care, and integration of treatment elements should support optimal functioning of youth

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Detoxification • Some substances warrant medical attention to manage safe withdrawal • Depressants such as alcohol and benzodiazepines carry risk of death from withdrawal if regular high-dose use exists • Other substance classes may carry physiological withdrawal symptoms that can be eased with appropriate detoxification • Counselors should provide support for psychological symptoms of transitioning from use to nonuse even if physical withdrawal is avoided

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Individual and Group Counseling • The following approaches are effective for addressing youth substance use disorders: – Cognitive behavioral therapy – Behavioral therapy and contingency management – Motivational enhancement therapy – Psychoeducation – Group Therapy – 12-step facilitation and 12-step group participation

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Integrating Family Into Treatment • Family involvement in treatment may be promoted through the following: – Psychoeducation – Family therapy, including: ▪ Brief strategic family therapy ▪ Family behavior therapy ▪ Multidimensional therapy ▪ Multisystemic therapy

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Community-Based Interventions • The following community-based treatment interventions promote systemic collaborations: – Adolescent community reinforcement approach – Recovery High programs • Community-based interventions target unique needs of youth and, when collaborations across systems occur, may promote significant change

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Psychopharmacotherapy • Lack of clinical data on efficacy of medications for treating youth substance use disorders • Informed by research on adults with SUDs • Decisions regarding medication should be made by trained medical professionals with firm understanding of risks and benefits • Medications may be used to ease withdrawal symptoms, reduce risk of relapse, and maintain abstinence from use

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Copyright This work is protected by United States copyright laws and is provided solely for the use of instructors in teaching their courses and assessing student learning. Dissemination or sale of any part of this work (including on the World Wide Web) will destroy the integrity of the work and is not permitted. The work and materials from it should never be made available to students except by instructors using the accompanying text in their classes. All recipients of this work are expected to abide by these restrictions and to honor the intended pedagogical purposes and the needs of other instructors who rely on these materials.

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Counseling Children and Adolescents First Edition

Chapter 17 Anxiety, Obsessive-Compulsive, and Related Disorders

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Anxiety, Obsessive-Compulsive, and Related Disorders • Anxiety is one of the most frequently diagnosed disorders in youth • Lifetime prevalence rates of anxiety in youth range from 15-20% • Lifetime prevalence rates for OCD in youth range from 13% • DSM-5 categorizes anxiety and obsessive-compulsive disorders separately

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Nature of Anxiety and ObsessiveCompulsive Disorders in Youth • Anxiety is a normal, functional response that is usually adaptive in nature but may become problematic if it impairs functioning • Fear is a response to a real perceived threat while anxiety is a response to an anticipated threat • Fears may be classified into five domains: – Fear of failure and criticism – Fear of the unknown – Fear of animals and injury – Fear of death and danger – Medical fears Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Symptoms of Anxiety-Related Problems (1 of 2) • While some anxiety concerns may be obvious, many may be masked by co-occurring problems, behavior issues, environmental or developmental stressors, or dysfunctional family dynamics • Symptoms typically fall into three distinct but related domains: somatic, cognitive, and behavioral

• Young children are likely to report somatic symptoms • Physical symptoms affect the cognitive domain • Fear of losing control is common in anxious youth

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Symptoms of Anxiety-Related Problems (2 of 2) • Anxious youth typically fail to realize connection between physical, cognitive, and behavioral elements

• Helping youth understand these connections underlies the counseling process • Youth with anxiety often turn inward and internalize feelings of anxiety • Avoidance behaviors are the best attempt at managing symptoms • Symptoms may vary in intensity, duration, and frequency and may manifest differently in different situations and settings Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Types of Anxiety Disorders • Common experience of excessive, irrational fears and dread • DSM-5 anxiety disorders among youth include: – Separation anxiety disorder – Selective mutism disorder – Specific phobia – Social anxiety disorder – Panic disorder – Agoraphobia – Generalized anxiety disorder

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Assessment of Anxiety Disorders • Assessment may include interviews, self-reports, behavioral observations, parent-teacher rating scales, and family assessments • Assessments should involve varied measures of data collection regarding symptoms in multiple settings

• Standardized assessment tools may be used • Attention to developmental factors, age of onset, and consideration of co-occurring disorders is important

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Symptoms of Obsessive-Compulsive and Related Disorders • Characterized by obsessions (recurrent, intrusive, unwanted thoughts, images, or urges), compulsions (repetitive physical or mental acts), and/or persistent body-focused repetitive behaviors • Youth have usually tried and failed to stop thoughts and behaviors on their own • Symptoms may be poorly articulated and compulsions may exist without clear obsessions • Symptoms are time consuming, impair functioning, and cause significant distress

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Types of Obsessive-Compulsive Disorders • Obsessive-compulsive disorders include the following DSM-5 diagnoses: – Obsessive compulsive disorder – Body dysmorphic disorder – Trichotillomania • Excoriation disorder

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Assessment of ObsessiveCompulsive and Related Disorders • Through assessment involves evaluation of past and current symptoms, current level of severity and functional impairment, and comorbid disorders • Diagnostic interview is the most effective means of assessment, and may be augmented with standardized assessment measures

• Thorough assessment considers differential diagnoses and comorbid disorders

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Counseling Interventions • Available research suggests that CBT is the most evidence-based approach for treatment • Involve cognitive restructuring, repeated exposure and response prevention, and skills training

• Little research focuses on adolescents and children • Combined treatments involving SSRIs and CBT have highest remission of symptoms

• Multiple factors may influence treatment effectiveness • Additional treatments include ACT and DBT

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Integrated Treatment Components: Anxiety and Obsessive-Compulsive Disorders (1 of 3) • Treatment focuses on skills training, development, and practice • May involve education, learning coping skills, and behavioral exposure with ritual prevention for OCD

• Relapse prevention may also be addressed with OCD • Components may be piecemealed together or completely integrated based on client needs

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Integrated Treatment Components: Anxiety and Obsessive-Compulsive Disorders (2 of 3) • Treatment modalities may include: – Relaxation training – Affective education – Awareness of physical, cognitive, and behavioral symptoms – Social skills training – Cognitive skills training

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Integrated Treatment Components: Anxiety and Obsessive-Compulsive Disorders (3 of 3) • Treatment modalities may include: – Problem solving – Contingent reinforcement – Habit reversal training – Exposure-based procedures – Integration of family

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Psychopharmacotherapy • Medications may be used to manage youth anxiety and obsessive-compulsive disorders • When considering referral for evaluation, youth should consider current distress and functioning, severity of symptoms, and mental health history • SSRIs may be used to manage symptoms of anxiety and obsessive-compulsive disorder in youth

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Copyright

This work is protected by United States copyright laws and is provided solely for the use of instructors in teaching their courses and assessing student learning. Dissemination or sale of any part of this work (including on the World Wide Web) will destroy the integrity of the work and is not permitted. The work and materials from it should never be made available to students except by instructors using the accompanying text in their classes. All recipients of this work are expected to abide by these restrictions and to honor the intended pedagogical purposes and the needs of other instructors who rely on these materials.

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Counseling Children and Adolescents First Edition

Chapter 18 Depressive and Bipolar Disorders

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Depressive and Bipolar Disorders • Prevalence rates are around 11% for depressive disorders and 3% for bipolar disorders in youth • Gender differences exist for depressive disorders, which are more common in females • No gender differences exist for bipolar disorders • Risk for developing depressive and bipolar disorders increases significantly when a family member has the disorder

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Nature of Depressive and Bipolar Disorders in Youth • Depression involves sadness and melancholy that impacts energy levels and thoughts about themselves • Bipolar disorders involve experiences of mania or hypomania—elevated mood states—along with shifts between elevated and depressed mood states • With mixed features is a specifier for bipolar disorder that reflects simultaneous experience of depression and elevation of mood

• Depression and bipolar disorders may be overlooked in youth for a variety of reasons

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Symptoms of Depression (1 of 2) • Criteria for depression in adults is typically used to diagnose depression in youth • Age and development may influence symptoms • Younger children are more likely to experience physical symptoms

• Hypersensitivity to criticism is a consistent symptom • Some social withdrawal may be seen in adolescents • Youth tend to interpret experiences negatively and fixate on deficiencies and hopelessness • Depression may involve a range of behaviors, symptoms, and functional impairments Copyright © 2019, 2012, 2006 Pearson Education, Inc. All Rights Reserved

Symptoms of Depression (2 of 2) • In girls, symptoms may also be experienced or manifest during menstruation • These symptoms characterize pre-menstrual dysphoric disorder • Suicide is an important consideration with depression in youth • Promoting emotional regulation is essential task of treatment for depressed youth

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Types of Depressive Disorders • Depressive disorders typically share symptoms of depressed mood and loss of interest in activities and include the following disorders: – Disruptive mood dysregulation disorder – Major depressive disorder – Persistent depressive disorder – Premenstrual dysphoric disorder

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Assessment of Depressive Disorders (1 of 2) • Assessment procedures vary based on age • Subjective nature of depression makes assessment process complex

• Clinical interview is the most effective means of assessment and may be augmented by observations, rating scales, and family assessments • Sometimes multiple modalities may present conflicting results due to this subjective nature • Assessment for mania/hypomania should be conducted to rule out bipolar disorder

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Assessment of Depressive Disorders (2 of 2) • Assessment of behavioral irritability are warranted • Failure to do so may result in masked depression

• Youth with depressive disorders are more likely to be diagnosed with another mental disorder • Depression and anxiety disorders often co-occur

• Behavior disorders, ADHD, and substance use disorders may also co-occur

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Symptoms of Bipolar Disorders (1 of 2) • Bipolar disorder diagnosis has increased dramatically in youth in recent years • Symptoms include mania or hypomania – Extreme, dramatic changes in mood, energy, thinking, perceptions of reality, and behavior

• Younger children typically present with fewer acute symptoms and better interepisodic functioning • Adolescents experiencing first manic phase may have especially dramatic symptoms

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Symptoms of Bipolar Disorders (2 of 2) • Unrealistic beliefs may border on psychosis • Frequently involve inflated self-worth, power, knowledge, identity, or relationship with someone famous and are immune to logic, reason, and proof • Social relationships may be negatively impacted by these grandiose beliefs • May also increase distractibility and decrease focus, attention, productivity, and decision-making skills • Substance use and hypersexuality may occur • Inappropriate affect may also be a symptom

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Types of Bipolar Disorders • The following bipolar disorders affect youth: – Bipolar I disorder

– Bipolar II disorder – Cyclothymic disorder

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Assessment of Bipolar Disorders (1 of 2) • One of the more complex disorders to accurately identify and diagnose

• Thorough assessment required to ensure criteria for manic/hypomanic episode have been met • Multiple reports from different adults in child’s life should be collected and standardized assessment measures may also be used • Interviews with youth and adults should be separate

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Assessment of Bipolar Disorders (2 of 2) • Youth may be misdiagnosed with ADHD, depression, borderline personality disorder, or PTSD • Differential diagnoses should be considered, particularly D MDD

• Co-occurring disorders should also be considered

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Counseling Interventions • The following interventions are effective and empirically supported for depressive and bipolar disorders in youth: – Cognitive behavioral therapy – Behavioral activation therapy – Interpersonal therapy – Interpersonal and social rhythm therapy – Family-focused treatment – Dialectical behavior therapy

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Integrated Treatment Components (1 of 2) • Treatment in stabilization and maintenance phases of counseling typically addresses: – Affective education – Coping and problem-solving skills – Cognitive restructuring – Developing positive beliefs and feelings about oneself • Bipolar treatment is tailored to the stage of the disorder: acute, stabilization, and maintenance

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Integrated Treatment Components (2 of 2) • Individual components may be integrated into treatment depending on setting, theoretical orientation, and client and family needs and include: – Psychoeducation (affective education) – Cognitive restructuring – Problem-solving approaches – Activity scheduling – Family involvement

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Psychopharmacotherapy (1 of 2) • Research supports medication use with depressive and bipolar disorders in youth • SSRIs (for depression) and mood stabilizers, antipsychotics, and anticonvulsants (for bipolar disorders) are often used • Not all of these medications have been approved by the FDA for use with youth

• Medication is essential and typically required to address sever depression and bipolar disorders • Risk of exacerbation of symptoms and suicidality exists with antidepressants in youth

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Psychopharmacotherapy (2 of 2) • Medication compliance may be a concern relevant for integration into counseling

• Counselors may also have opportunities to recognize medication side-effects observed in session • Counselors should collaborate and consult with physicians for clients with medication reactions and remember medication management is outside of counselors’ scope of practice • Sometimes medication that is partially effective will be augmented with another medication

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Copyright

This work is protected by United States copyright laws and is provided solely for the use of instructors in teaching their courses and assessing student learning. Dissemination or sale of any part of this work (including on the World Wide Web) will destroy the integrity of the work and is not permitted. The work and materials from it should never be made available to students except by instructors using the accompanying text in their classes. All recipients of this work are expected to abide by these restrictions and to honor the intended pedagogical purposes and the needs of other instructors who rely on these materials.

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Counseling Children and Adolescents First Edition

Chapter 19 Physical Health-Related Counseling Issues: Eating Disorders, Elimination Disorders, and Chronic Illness/Disability Counseling

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Eating Disorders Overview (1 of 4) • Characterized by persistent disturbance of eating behaviors resulting in altered consumption or absorption of food • Overvaluation of shape or weight is usually present • In anorexia, youth may fail to recognize seriousness of low body weight • Dangerous behaviors that accompany eating disorders can be life threatening and have dire medical consequences • Immediate treatment is warranted due to this risk

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Eating Disorders Overview (2 of 4) • Negative influence on brain functioning, metabolism, and neurochemistry, which limits cognitive functioning, decision making, emotional stability, and life activities • Counselors should have specialized training if they work with youth with eating disorders

• Regular consultation, supervision, and ongoing education are essential • Level of impairment requires initial focus on factors maintaining behavior rather than causing it

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Eating Disorders Overview (3 of 4) • Typical age of onset is age 12 for both disorders

• Early identification and intervention can prevent symptoms from becoming entrenched • Evidence-based behaviors and team approach to treatment can promote recovery • Anorexia nervosa has the highest mortality rate of any psychiatric disorder • Research suggests adolescents who are ill for less than 3 years have a good chance at making full psychological and weight recovery

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Eating Disorders Overview (4 of 4) • Recovery rates for bulimia vary considerably • Poorer outcomes were found with earlier age of onset, severity of symptoms, comorbid diagnoses, and personality characteristics

• Rapid reduction in symptoms during first 4 weeks of treatment is associated with positive outcomes • Family and other adults may struggle with how to respond to this popuation

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Anorexia: Symptoms and Counselor Considerations (1 of 2) • Involves significantly low body weight • Other medical issues should be ruled out • Growth charts, exploration of eating and weight management patterns may all provide useful data • Two subtypes: restricting and binge-eating/purging • Maladaptive beliefs surrounding weight, shape, and appearance and disregard for seriousness of low body weight are typically present • Intense fear of gaining weight or becoming fat

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Anorexia: Symptoms and Counselor Considerations (2 of 2) • Thorough medical evaluation and interdisciplinary treatment team are essential for safe treatment

• Chronic malnutrition can lead to major medical complications and must be assessed and addressed • Partnerships with psychiatrists can also help manage comorbid disorders • Important ethical considerations include adequate training to provide ethical care, assessment of necessity of higher level of care, and active engagement and involvement of family Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Bulimia: Symptoms and Counselor Considerations (1 of 2) • Characterized by recurrent episodes of binge eating plus compensatory behaviors to prevent weight gain • Behaviors may include self-induces vomiting, laxative and diuretic misuse, enema use, excessive exercise, fasting, and abuse of insulin in youth with diabetes • Also require self-evaluation that is significantly influenced by weight or shape • Approximately 10-15% of those with bulimia are male • Sport participation and sexual orientation may be risk factors for males Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Bulimia: Symptoms and Counselor Considerations (2 of 2) • Consideration of medical complications is essential • Counselors must coordinate care with medical professionals to manage health risks • Determination of proper level of care is important, and may be indicated by progress in first four sessions • Those with bulimia may be at risk for other comorbid disorders related to impulsivity, affective instability, and disinhibition • Less cultural variation exists with bulimia than with anorexia nervosa Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Anorexia Nervosa: Treatment Models and Interventions (1 of 3) • Family-based treatment (the Maudsley Method) is the treatment of choice • Outpatient treatment model, typically takes 1 year to complete, developed for teens who reside with family • Overall philosophy includes that family involvement, especially from parents, is critical for success • Adolescent is viewed is too ill to make sound decisions about eating and related behaviors

• Parents take control of child’s eating and activity until child is less physically and psychologically ill Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Anorexia Nervosa: Treatment Models and Interventions (2 of 3) • FBT also attends to development and helps family navigate normal developmental tasks

• Three clearly defined phases: – Weight restoration – Transitioning control of eating back to the teen – Adolescent issues and termination • Currently considered first-line treatment for youth with anorexia nervosa and especially effective with youth who have relatively short illness duration

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Anorexia Nervosa: Treatment Models and Interventions (3 of 3) • Other evidence-based treatments include: – Cognitive behavior therapy – Enhanced cognitive behavior therapy for eating disorders – Psychopharmacotherapy ▪ Limited evidence supporting use in youth ▪ SSRIs may increase risk of suicidality ▪ Antipsychotics may be used off label, with limited research support ▪ Medication should not be the first line treatment Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Bulimia Nervosa: Treatment Models and Interventions • The following interventions have demonstrated efficacy for treating bulimia nervosa: – Cognitive behavioral therapy – Dialectical behavioral therapy – Family-based treatment model – Psychopharmacology ▪ Some evidence of SSRI efficacy with co-occurring depression, anxiety, and suicidality ▪ Medication may be used as adjunctive treatment along with first-line CBT Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Elimination Disorders (1 of 2) • Enuresis involves inappropriate elimination of urine into bedding or clothing • Encopresis involves inappropriate elimination of fecal matter (intentional or unintentional) • Before age 4 for encopresis and age 5 for enuresis, these behaviors may occur due to accidents • Co-occurrence due to developmental delay likely does not warrant diagnosis • Counselors should consider whether difficulties are due to physical illness prior to diagnosis

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Elimination Disorders (2 of 2) • May cause embarrassment or shame • Causes include psychological factors, genetics, and biological factors • Youth with history of physical or emotional abuse may experience enuresis, but not all youth with elimination disorders have abuse history • Coping with these disorders can be especially challenging for parents and caregivers • Experiencing frustration regarding symptoms may exacerbate the disorder and elimination difficulties

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Enuresis: Symptoms and Counselor Considerations (1 of 2) • Includes urination in bed or clothing at least twice per week for three consecutive months, or to the point where youth experiences significant distress • Three specifiers specific to time of day (nocturnal, diurnal, or both) • May be primary or secondary • One of the most common disorders in youth

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Enuresis: Symptoms and Counselor Considerations (2 of 2) • Contributing factors may include: – Environment – Stress – Infections and overactive bladder muscles – Discomfort with using the restroom – Avoidance of stopping fun activity – Inconsistent bathroom schedule – Genes and biological factors • Symptoms should be assessed by physician • Prognosis is generally good Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Encopresis: Symptoms and Counselor Considerations (1 of 2) • Characterized by repeated voiding of feces in inappropriate places at least once every 3 months • May not occur due to medical condition (with exception of constipation) • Two subtypes: with constipation and overflow incontinence (involuntary), and without constipation and overflow incontinence (believed to be voluntary) • May be primary or secondary

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Encopresis: Symptoms and Counselor Considerations (2 of 2) • Contributing factors may include: – Constipation – Fear or embarrassment – Avoidance of ending fun activity – Byproduct of extended sitting – Harsh potty training – Stress – Frustration with initial symptoms – Biological complications of initial symptoms – History of abuse or neglect, including sexual abuse – Behavior problems (without constipation) Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Counseling Interventions and Treatment • Thorough assessment of psychosocial experiences, familial relationships, stressors, and medical professional assessment of biology and genes • Application of behavior therapy is most effective for both disorders after ruling out medical disorders • Involving families in treatment is important, as is beginning counseling as early as possible to avoid habit formation • Some cases may resolve spontaneously • Encopresis may require extensive interventions in some cases Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Enuresis Interventions and Treatment • The following interventions have demonstrated efficacy for treating enuresis: – Enuresis alarms – Operant conditional – Psychopharmacotherapy ▪ May involve hormones to regulate urination and TCAs to increase awareness of need to urinate in conjunction with behavioral interventions ▪ Risk of relapse following medication cessation

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Encopresis Interventions and Treatment • The following interventions have demonstrated efficacy for treating encopresis: – Toilet education and training – Behavior management – Nutritional changes/medications ▪ Should encourage clients to consult medical professionals to inform changes and potential medications (i.e., laxatives, stool softeners)

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Chronic Illness/Disability Counseling • Some youth experience chronic illness or disability at birth or throughout childhood • May impact physical and psychological development • Impact is constant, challenges are difficult, and youth and family are emotionally, physically, and mentally stressed and/or exhausted • Estimated that 1 in 4 youth have at least one chronic health problem with a wide range of severity • Process of accepting and managing chronic health challenge may be difficult

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Physical and Health-Related Conditions (1 of 2) • A chronic health condition is defined as lasting 3 months or longer, affects day-to-day activities, and requires specific medical attention • May involve symptoms of pain and discomfort

• May consume a great deal of time and energy

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Physical and Health-Related Conditions (2 of 2) • Some examples include: – Asthma – Diabetes – Cerebral palsy – Sickle cell anemia – Cystic fibrosis – Cancer – HIV/AIDS – Epilepsy – Spina bifida, severe food allergies/intolerances – Congenital heart defects Copyright © 2019 Pearson Education, Inc. All Rights Reserved

Adjustment to Chronic Illness/Disability • Response and adjustment influenced by personal characteristic, levels of support, rarity of illness, nature of treatment, and course, nature, and severity of illness • Youth typically respond in developmentally-congruent and expected ways, and age is an important factor related to youth adjustment to illness • Family members may experience grief and stress, which may be internal, external, or physiological • Siblings may be tasked with increased responsibility

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Counseling Interventions • Recognition and management of stress is essential for parents and youth with chronic illness • Counselors can support youth and families during adjustment period and course of illness • Understanding of the illness in context and its impact on youth emotions, functioning, concerns, and expression is essential • May help youth with skill development, emotional processing, and health behaviors • CBT, BT, and SFBT are evidence-based practices • Family support and involvement is important

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