17
Interdisciplinary Group Therapy with Children
Marita Rademeyer1,2,3 and Deirdre Niehaus4
1 Clinical Psychologist private practitioner, Pretoria, South Africa
2 Chairman, Jelly Beanz Inc. NPO, Pretoria, South Africa
3 Co-founder Child Trauma Clinic, Pretoria, South Africa
4 Occupational Therapy private practitioner, Maputo, Mozambique
Introduction
Interdisciplinary group therapy is a method of treatment developed to simultaneously address childrens’ developmental and psychosocial difficulties that would otherwise require psychotherapy as well as occupational therapy. Children who show developmental and social or emotional difficulties and who do not have access to, or do not benefit optimally from, multiple individual therapies may benefit from interdisciplinary group therapy. In the South African context, where the majority of children do not have access to mental health services (Lund et al. 2009), this modality of treatment is well suited to make services available to more children.
Suitable candidates for group therapy are placed in groups of four or six with an occupational therapist and psychologist who act as co-therapists. The therapists plan and execute therapy in accordance with the content–process model of group therapy (Rademeyer & Niehaus in Crouch & Alers 2005).
Interdisciplinary group therapy was developed in an effort to address the needs of children with multiple difficulties, by overcoming limitations of individual therapy and embracing the benefits of group therapy. Children with multiple difficulties often need the input of two or even more therapists to address their problems. This can be very costly, time consuming and may create difficulties for the parents/caregivers in that the different modalities of therapy require different inputs from parents.
Group therapy aims to treat primary or secondary developmental, as well as psychosocial, difficulties simultaneously. When a child shows a developmental delay, secondary emotional and/or social difficulties quite often develop. A child with poorly developed gross motor skills would not be able to take part freely in peer group activities such as ball playing, thus may withdraw socially, and have fewer opportunities to develop social skills. The child may also become aggressive or defiant. A child with perceptual difficulties may struggle to cope in the classroom and may be aware that his/her performance does not compare favourably with that of other children. Emotional difficulties such as low self-esteem, lack of confidence, anxiety or aggression and acting-out behaviour may develop. In these examples, a primary developmental delay has led to a secondary psychosocial difficulty.
A primary psychosocial difficulty could also lead to secondary developmental difficulties. A child who has been severely traumatised is trying to make sense of his/her experiential world and may not engage in activities that stimulate development. A child from a dysfunctional family may not have adults around who create appropriate opportunities for growth. A child who is very anxious may withdraw from interaction or be shunned by other children. A child who is aggressive may be rejected by peers and excluded from play activities, which would stimulate development.
The content–process model of group therapy was developed as a way to implement the therapeutic principles of occupational therapy and psychological treatment simultaneously. The content of the group session refers to the actual activities that take place. These are planned in advance by the occupational therapist in accordance with occupational therapy practice. The activity is chosen to fit with the childrens’ therapeutic goals, developmental phase and phase of group development.
The process of the group session refers to all the interactions and behaviours that take place in the group, namely, the observable aspects, as well as the thoughts, experiences and feelings of group members, namely, the internal aspects. The process of the group will be influenced by amongst other factors:
- The personal histories and experiences of the group members as well as therapists
- The temperament, personality aspects and behavioural patterns of members
- The phase of development of the group process
- The input of the therapists
- The activities chosen for the session
The occupational therapist uses the group content to address developmental goals, and the group process is used to facilitate emotional healing and social growth. A group of six-year-old children, whose fine motor skills need to be developed, may be asked to make puppets, involving cutting and fine motor manipulations (content). When the puppets have been completed, they may be encouraged to stage a puppet show, which creates opportunities for expressing children’s current concerns and promoting interpersonal problem-solving (process). The content and process come together by the scaffolding offered by the co-therapists for the children to work together.
Indications for and against interdisciplinary group therapy
Interdisciplinary group therapy shows encouraging results in the treatment of:
- Problematic peer group functioning
- Lack of generalisation of skills after completing individual therapy
- Learning difficulties, which include developmental as well as psychosocial components
- Developmental difficulties with secondary psychosocial components
- Psychosocial difficulties with secondary developmental components
Group therapy might not initially be indicated for the following children:
- Children with sensory integration difficulties might first benefit from individual therapy until they can function and integrate the sensory demands within a group.
- Children from severely dysfunctional families, where a family therapy intervention may be the intervention of choice.
- Children with severe behavioural problems or very poor concentration.
- Children with impaired verbal communication may battle to cope with the demands placed on them in terms of interactions with other children. These children may benefit from a therapeutic intervention such as Developmental, Individual Differences, Relationship-Based (DIR) Floortime therapy (Greenspan & Wieder 2006) until they have developed sufficient verbal communication skills.
- It is important that the therapists prioritise and keep in mind that individual work often needs to take place before group work is indicated.
- Potential group members are often referred to either an occupational therapist or a psychologist, depending on the presenting problems. In collaboration with the parents/caregivers, the team might decide to do separate assessments by both disciplines or may perform a multidisciplinary assessment where all the team members work with one or more children simultaneously. This model of assessment is particularly useful in contexts where limited human resources are available (especially in clinic settings or rural areas) or in cases where the child who is assessed does not speak the same language as one of the therapists. Assessments by the occupational therapist and the psychologist might include the following aspects: sensory integration; gross and fine motor functioning; visual perception; work habits; emotional, social and cognitive functioning; family functioning and dynamics; and functioning in the child’s natural environments such as home and classroom (visits to these areas are usually recommended) with additional information from educational and neuropsychological reports.
An example of how this would work in practice could be where the child is given an instruction to draw his family. The occupational therapist may observe aspects such as pencil grip, postural background movements, ideation, motor planning and execution, while the psychologist may gain information on the child’s experiences around the family. After the assessment, if both developmental and socio-emotional difficulties are present, the child may be included in an interdisciplinary group. Upon inclusion in a group, it is important to have information regarding the child’s developmental functioning as well as socio-emotional functioning, which is discussed by the co-therapists to establish the child’s affordances/strengths and challenges. In practice, it is useful to make a working summary of assessment results for each child, outlining the challenges and treatment aims. This summary is important in making the group placement and in guiding the planning of therapy.
The authors have found that to deal with both content and process optimally, it is ideal to have four to six children in a group. This means that a ratio of two or three children per therapist is maintained. If more children are included, it becomes more difficult to address the socio-emotional needs of all the children. The following factors should be considered when selecting group members:
- The children should be on similar levels of development with similar or associated developmental problems. The therapist would use the working summaries of potential candidates for comparison and selection.
- Children should be able to speak the same language.
- There should not be more that a 12-month chronological age difference between group members.
- The children should be on the same level of creative participation (de Witt 2005 in Crouch & Alers). Children of schoolgoing age should preferably be of the same sex.
Avoid the following situations in a group:
- Two children from the same family
- Two children who act out aggressively
- Two very hyperactive children
Interdisciplinary group therapy can be carried out in an occupational therapy area where all the standard equipment and activities are present. The occupational therapist should adhere to structuring principles in accordance with the children’s diagnoses, for instance, keeping dangerous equipment out of reach of impulsive, hyperactive or aggressive children. The area should be large enough for the children to move about and have a chance to move away from the ‘action’.
The content of the group includes the activities that the therapists choose to stimulate sensorimotor development. The content is also structured in accordance with the childrens’ psychosocial needs.
Activities are then chosen to address the treatment goals as set out in the working summary.
The activities are presented in three predictable parts in every session:
- Warm-up exercise: The goal is to make the children relax, connect with each other and open up. Having fun is essential in the early stages of each session.
- Main activity. The activity is aimed at improving developmental skills while addressing socio-emotional issues.
- Relaxation or winding down. This activity is aimed at helping the children calm down after the work done and transition into leaving the therapy area.
Requirements of the activities are as follows:
- The children need to gain a feeling of mastery so that the correct challenge is set for them to have an adaptive response and improve their developmental skills.
- Children should not perform the activities in isolation; in other words, each child should not perform his/her own activity. Children need to interact with each other in the process. When working on a puzzle, the sharing of equipment makes negotiation occur either in taking turns or collaborating with each other.
- The activity should fit with the group developmental phase. In the first phase of the group, it is important that emotional content not be too threatening, whereas in later phases, it is important that socio-emotional issues be addressed. In the termination phase, where children are preparing to leave the group, more individualised activities are more appropriate.
Activities are presented according to the following:
- Treatment goals.
- Phase of development, for example, in the first phase, the children might need more instruction and reassurance than in the later phases.
- Children’s individual needs. An anxious child may need more structure and predictability, while an aggressive child may need more overt limit setting.
The therapists use a process to facilitate psychosocial healing and growth. This is achieved as the co-therapists helps to create a therapeutic climate, or healing space. It is important for the therapists and group to establish the norms of respect, acceptance, support, sharing, caring, sensitivity to the needs of others and congruency. This is done by the following:
Forensic Psychiatry and Occupational Therapy
Sensory Integration in Mental Health
