Long-Term Treatment

, 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

ChildEmotions/FeelingsTherapy techniquesVerbal communicationNonverbal communicationPositive feedback

Table 5.1 presents the five long-term treatment goals. Similar to peeling back the layers of an onion, all the problems and difficulties these children have usually might not be apparent in the early stages of treatment. Therefore, pacing during each phase of treatment is most important and cannot be overstated. Moving too quickly or working on a goal before the child is ready can result in termination of treatment.

Table 5.1

Long-term child and parent treatment goals

Child goals	Parent goals
Recognize, monitor, and verbalize emotions	Revisit how parents manage stress during NES episodes
Identify stressors	Understand and facilitate family communication
Verbalize emotions associated with stressors	Recognize the child’s stressors
Connect negative emotions with NES symptoms	Identify family stressors
Problem-solve adaptively	Help child problem-solve

During the long-term treatment phase, it is essential that you continue to work with the child’s parents separately. Ideally see them on different days so that the child is not in the waiting room thinking about what you and the parents are saying about the child. Maintain your rapport with the parents, continue to engage them as your co-therapists, and be sensitive to early signs of resistance. The long-term parent goals (Table 5.1) help the parents understand and facilitate family communication, become sensitive to the different ways their child expresses difficulties and stressors, identify family stressors, and support the child’s problem-solving efforts. It is important that you schedule family sessions with the child only when the child is able to acknowledge and verbalize the need to meet with the parents to address issues that arise during the child’s therapy. Figure 5.1 presents useful road map suggestions for your long-term work with PNES children and their parents.

Fig. 5.1

Road map tips for treating PNES children and their parents

Child Long-Term Treatment Goal 1: Recognize, Monitor, and Verbalize Emotions

Children with PNES often are not in touch with the emotions associated with their experiences and thoughts particularly if these are negative and involve anger, hurt feelings, sadness, fear, and tension. This difficulty can stem from a variety of reasons including trouble connecting with and/or verbalizing emotions (alexithymia), a subtle language disorder, and fear of a negative angry response by others. Addressing this goal is essential from the beginning of the therapy because the episodes represent maladaptive physical expressions of these negative emotions. Helping the child recognize, verbalize, and monitor emotions using the techniques below should be part of the treatment plan for each session.

Probe for and Acknowledge Child’s Expression of Emotions

Throughout treatment, when the child shares information or describes a situation, ask: “And how did that make you feel?” This simple technique draws the child’s attention to the fact that most situations involve some emotion(s). It also encourages the child to first reflect, “Do I feel something?,” and then to verbalize the emotion. You should both empathize with the child about the emotion the child expresses and provide positive feedback every time the child talks about an emotion or emotional experience.

Wow.
When that happened, did you feel sad, mad, scared, or…?
And that made you feel…?
You are doing such a good job talking about….

Identify and Monitor Emotions

Help the child tune in and track positive and negative feelings that arise during the child’s daily activities. In doing so, be attuned to the child’s subtle expressions of emotion. The techniques in Table 5.2 guide you on how to encourage the child to talk about feelings.

Table 5.2

Techniques that encourage talking about feelings

Technique	Response
Let’s talk about feelings ^a
“Some kids know what they are feeling but sometimes it gets all jumbled. Let’s talk about some of the feelings you know that you have and how you can tell you are feeling that way.”	“Nothing,” “I don’t know,” or a shoulder shrug are highly likely in the early treatment stages. Although less likely, they occur even in the later stages. The extent of the verbal response also varies by age. An older child may come up with a paragraph whereas a younger child may give only a one-word answer
Identify emotions in others ^b
Practice by using pictures and/or scenarios you make up that might be of relevance to the child. Then gradually encourage the child to talk about the emotions of people close to the child. • What does mom (dad, brother, or sister) do when angry? Always follow up with: • How does that make you feel? And/or • What do you do when that happens?	Most children find this easy to do Eliciting actions in those close to the child help the child describe situations that might induce the child’s negative feelings Early in treatment, child might avoid responding These follow-up questions help provide some insight on how the child feels
Use technology to normalize feelings	Some children/teens respond well to technical information
• Show the child a brain scan that demonstrates involvement of different brain parts when people experience positive and negative emotions • Use cell phones and/or social media to see what emotions peers express, what they might mean, and how to filter this information	This helps normalize that everyone experiences emotions that are controlled by the brain even if they are negative
Direct probes of the child’s feelings
Journal Suggest that the child use a cell phone or pocket notebook to remind the child about experiences that did not feel good Checklist Provide the child with a problem and stressor checklist, ask the child to create a problem list or, if necessary, do it with the child Severity ranking Encourage the child to rank the child’s emotions from the most bothersome to the least	Teens are more responsive than younger children Helpful for all ages Helpful for all ages
Indirect probes of the child’s feelings
Ask the child to write (dictate in the case of learning problems) a letter to the doctor about what does not feel good Let the child draw, use clay, paint, or other art forms while talking. This might calm and help the child verbalize ongoing thoughts and feelings Create a play with the child in which the different actors experience physical feelings, difficult or stressful situations, or emotions	Good for all ages Helpful for younger children Positive response in younger children

To apply ^a and ^b, see feelings checklist in Appendix G

Attend to the Child’s Nonverbal and Verbal Cues of Discomfort

Children with PNES become overwhelmed easily when exploring experiences that evoke negative emotions. Early in treatment, this might trigger an episode. As treatment continues, the child becomes better at controlling the episodes. It is important to pay attention to the nonverbal (more frequent) and verbal cues that suggest the child is uncomfortable or struggling when asked to describe feelings. These cues should guide you on whether you should or should not continue the ongoing topic of conversation. Nonverbal cues include:

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