338 Chapter 40
and self-administered treatments (using DVDs, or online). However, two
major trials in recent years, one in the USA (‘TADS’) and one in the
UK (‘ADAPT’) showed that while CBT alone is effective for depression,
medication (fluoxetine) is more so. Precise decision rules are still being
researched for when CT should tried, when medication, and when both
(see Chapter 10).
Anxiety and fear
Again, practice in children and adolescents has followed that in adults.
Similar techniques are used, including correction of distortions in think-
ing; identification of physiological responses, body sensations and their
interpretation; development of positive self-talk, guided imagery enabling
mastery over fear-provoking situations; relaxation during exposure; and
behavioural experiments whereby the child or adolescent puts themselves
into the anxiety-provoking situation and monitors whether what happens
is as bad as they feared. Randomised trials show good results, with over
half of cases being returned to the normal range.
Aggression
Aggressive children and adolescents have been shown to do the
following:
Perceive far more hostile cues in social situations.
Attend to fewer cues when interpreting the meaning of others’
behaviour.
Attribute hostile intentions to others in ambiguous situations.
Underperceive their own level of aggressiveness.
Generate fewer verbal, assertive solutions to conflict situations but more
physically attacking ones.
Believe this aggression will reduce aversive reactions from others and
gain them tangible positive outcomes.
Aggressive children and adolescents additionally believe aggressive be-
haviour will increase their self-esteem, and value dominance and revenge
more, and social affiliation less, than controls. Interventions usually target
these cognitive anomalies, but also address general interpersonal social
skills (see below), with a particular emphasis on slowing down automatic,
immediate reactions to provocative situations in order to allow more delib-
eration about suitable responses. Trials have shown significant reductions
in aggressive behaviour using social skills methods, persisting at one- and
three-year follow-ups. Effects in prepubertal children are enhanced by
the addition of parent-training programmes. However, purely cognitive
approaches mostly fail to have any effect in real-life situations: aggressive
adolescents can learn to stop, calm down and choose a negotiated settle-
ment to a hypothetical dispute, but direct observation during encounters
with peers, and self-reports of numbers of fights tend to show little impact.
It may be that the fast physiological arousal that occurs in antisocial youths
in confrontative situations leads to ‘visceral’ aggressive responding that
over-rides thinking processes learned in calm contexts.