Selection of a Psychotherapeutic Strategy

Factors that may influence the selection of a psychotherapy strategy include the nature of the psychological problem (e.g., pain, anxiety, somatization), the level of personal functioning, the degree of psychological insight, illness perception, and interper sonal skills. The assessment should take into account the child's level of cognitive and emotional development, intellectual capacity, and ability to assume responsibility. The assessment should include a comprehensive evaluation of parental understanding of the disease and its impact on the broader family system.

Children who are flexible and who have a wide repertoire of coping responses are more likely to benefit from an insight-oriented treatment approach. By contrast, patients who have a greater tendency to use denial, avoidance, and other less adaptive coping strategies are more likely to respond to supportive and/or CBT approaches. The choice of treatment may also be influenced by the stage of the child's illness. For example, treatment at the time of diagnosis or during a relapse may require a supportive approach in contrast to insight-oriented psychotherapy during more quiescent phases of the illness. The child's belief about his or her illness, influenced by the child's cognitive development, is another important factor to consider in designing a therapeutic approach (see Table 28-4).

At times, an integrative approach including psy-chopharmacology is necessary (Szigethy et al. 2006). Circumstances in which adjunctive psychotropic medication should be considered include 1) the failure to respond to psychotherapy; 2) the presence of severe psychiatric comorbidity (e.g., mood disorders or eating disorders); 3) the presence of acute agitation or psychotic symptoms; and 4) a family history that includes a first-degree relative who has responded positively to medications. The reader is referred to Chapter 30, "Psychopharmacology in the Physically Ill Child," for a fuller discussion of psy-chopharmacological considerations.

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