Child Long-Term Treatment Goal 2: Identify Stressors

, Julia Doss², Sigita Plioplys³ and Jana E. Jones⁴

(1)

Department of Psychiatry, UCLA, Los Angeles, CA, USA

(2)

Department of Psychology, Minnesota Epilepsy Group, St. Paul, MN, USA

(3)

Department of Psychiatry, Northwestern University, Chicago, IL, USA

(4)

Department of Neurology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA

Keywords

StressorsStress IndicatorsCopingAvoidancePhysical symptomsEmpathyModelingStory-telling

How to Help the Child Identify Stressors

As for Goal 1, identification of the child’s stressors involves a gradual process that starts with the more easily identifiable problems that were apparent during the diagnostic evaluation. It continues as you and the child explore problems that are harder for the child to acknowledge, label, and talk about. The 4 C tips in Fig. 6.1 and the techniques in Sections “Mapping Potential Stressors”, “Storytelling”, “Revisit”, “Provide Positive Feedback and Empathize”, and “Bridge to Coping and Problem-Solving” will assist you in helping the child to identify stressors.

Fig. 6.1

The 4 C tips for identifying stressors

Mapping Potential Stressors

For stressors at home and in the family, ask questions, such as “Who in your family is the funniest?,” “Who in your family is the quietest?,” and “With who in your family would you like to spend more one-on-one time?” Explore the child’s experiences at school and with friends using similar questions to identify possible stressors. The child’s answers to these questions give information about family relationships, communication, and possible stressors. But, identification of potential stressors early in treatment does not mean that you should label them as such. As emphasized in Goal 1, proceed cautiously and only address a stressor when the child becomes aware of its impact on the child’s emotions and functioning. See Appendix K for a worksheet to help child identify stressors.

Storytelling

Suggest that the child play a story game with you. You each take turns to tell different parts of a story. Ask the child who should begin the story. Each storyteller decides when it is the turn of the other individual to continue the story. If the child decides to start the story (which is preferable), pay attention to what the child’s story might actually be telling you. When the child wants you to continue the story, introduce elements that might be of relevance to the child (e.g., one of the child’s stressors), what the protagonist feels, and how the protagonist problem-solves. If the child wants you to start the story, choose a topic related to the child’s potentially stressful experiences or difficulties.

For the game to be less personal, however, describe the protagonist as being a person from very far away in a different land. With younger children, you could begin: “Once upon a time, far away in …, there was a girl named …” (“Now it is your turn …” ). “Every day, … would….” (“It’s your turn again”). If the child enjoys this game and enthusiastically speaks during his/her turns, move to more challenging story game topics (involving stressors the child is experiencing) during subsequent sessions. You might also start by saying: “I want to tell you a little about someone that I used to work with who had similar difficulties. This child described things getting harder (difficulties with) when …”.

Revisit

Consider talking about worries the child might have told you about and find out if there are additional ones. Another approach is to ask the child about things the child does not like and that “bug” the child.

Provide Positive Feedback and Empathize

Since these children usually get negative feedback at home and school, they really appreciate and thrive on any affirmation they receive. So, acknowledge and give positive feedback every time the child describes a stressor, negative emotion, and unpleasant experience no matter how minute a detail it might be. Then empathize with how the child felt in these situations.

Bridge to Coping and Problem-Solving

If the child provides you with information about a stressor or a difficult situation, always ask the child “How does that make you feel?” and “When you experience …, what helps make it better?” and then follow-up with “And what doesn’t help when … happens?”

Dialogue: How to Identify Stressors

The child in the dialogue below is 10 years old and has had several therapy sessions for her PNES. Her episodes have ceased, and she has begun to focus on stressors. The therapist is trying to elicit information about the child’s life and family to understand what the child experiences at home and her difficulties. As you read the dialogue, think about the previously described 4 Cs and therapy techniques presented below in Fig. 6.2. The blue bubbles include comments about the therapist’s approach, and the yellow bubbles present comments about the child’s responses.

Fig. 6.2

Summary of Cs and Goal 2 Techniques

Therapist: We’ve spent a lot of time talking about your episodes, and you’ve done a great job getting them under good control! I was thinking that maybe I could get to know you a little better, know who the important people are in your life, and what they are like.

Child: Okay.

Therapist: Let’s start with who you live with. Can you remind me again who’s at your house?

Child: Well, I’ve got two houses.

Therapist: That’s right, so you’ve got two sets of people at two different places, right?

Child: Yep. At my Mom’s it’s me and my brother, my mom, and her boyfriend. And at my dad’s it’s him and my step-mom and my step-sister, but my brother doesn’t go over there all the time.

Therapist: Okay, so you’ve got your brother with you at your mom’s house and at your dad’s it’s just you and your stepsister? Do you think we could draw this out so that I can keep track (gets out drawing things, sits on the floor with child, and starts creating a map)? Sometimes it’s easier for me to remember if we put it on paper.

Child: That looks kind of like a family tree that I did in history.

Therapist: That’s right. We can make it look like that and maybe even add some other things in so that I can remember better. Like stuff about relationships. So, who in your family would you say is the funniest?

Child: Probably my dad. He always tells jokes.