16 Vivyan Alers Occupational Therapy private practitioner, Midrand, South Africa Director, Acting Thru Ukubuyiselwa NPO, Johannesburg, South Africa In some countries, including South Africa, occupational therapy in the field of child and adolescent mental health must be seen to be a priority because of the prevalence of abused children, emotionally, physically and sexually, and because of the many children who are brought up in impoverished and violent circumstances. Relationships that are expected to be part of nurturance and protection for the child, which turn in reality to physical or emotional abuse or neglect, have a psychological impact on the child, especially when these relationships are expected to be protective and nurturing (Emery & Lauma-Billings in Rutter 2002). Hudgins (2002) describes the ‘abandoning authority’ type of abuse, which causes a conflict in the child’s mind due to the reality (as neglect) and the expectation (protection and nurturance) of the caregiver. The attachment theory is based on the attachment of the child to the primary caregiver, and the style of attachment shows the child’s strategies of survival (Crittenden 2013). Impairment of psychosocial functioning is by far the largest group of disorders in children, and therefore, emphasis is placed on these disorders, and the occupational therapist is considered a vital member of the multidisciplinary team. The child and the family within the community are the focus, but mention will be made of the treatment of children within a day-hospital and inpatient setting. Psychiatric disorders impact on a child’s ability to function in all areas of development and especially in his/her psychosocial environment. The occupational therapist using a bio-psycho-social framework is well trained to integrate the complexity of the interactions between the infant, developing child, parent, caregiver, environment and culture. The complexity of this interaction means that the occupational therapist should have psychological maturity, experience with children and a good knowledge of the models, philosophies, frames of reference and theories of the profession so that the children can be treated in a holistic, all-encompassing manner. A sound knowledge of child development, conscious evasions (self-defence mechanisms) and unconscious defences (transferences and countertransferences) and projective identifications is also required. The occupational therapist needs to be familiar with the Children’s Act of the country and child protection services available. The psychosocial disorders of childhood are not defined in this chapter. Please refer to the following literature for the description of conditions: Stern (1985) describes the process of attachment as a process of affective attunement. This is the interpersonal exchange of affect that occurs between the mother/caregiver and the baby. This relates to the ‘dance’ of nuances, sounds, touch and interaction between the mother and the baby that relates to the underlying feeling states. These vitality affects help infants to regulate and integrate their feeling states, which leads to an early development of a sense of self. Each infant is biologically programmed for survival, with the limbic system operating the survival instincts, including the traumatic stress reflexes of fight, flight and freeze. The experiences of early infant life have a far-reaching effect on the emotional and social being of the child in later life. The attachment patterns that a child develops through his/her experiences of how early care needs are met have a lasting effect on their later attachment patterns in life and thus on interactions in society. Ainsworth and Crittenden built on the theory of Bowlby to develop the attachment theory. The styles of attachment were developed by Ainsworth et al. (1978) to the A/B/C patterns of attachment, which were then formulated into the Dynamic-Maturational Model of Attachment and Adaptation by Crittenden (2013). This is described in Chapter 21. The implications of understanding attachment theory for the occupational therapist lie in the importance of a consistent, trustworthy therapeutic relationship to model, and for the child to experience secure attachment patterns. The therapist in effect becomes the secure base. When the learning disabled child displays behavioural problems, the occupational therapist needs to consider the underlying reasons related to his/her attachment styles. Problems exhibited by children with disorganised attachment behaviour (Ainsworth et al. 1978) can include the following: In First World countries, the typical multidisciplinary team still exists in hospitals and clinics where the psychiatrist, child psychologist, occupational therapist, speech and hearing therapist and psychiatric nurse work hand in hand. Hospitalisation is usually when the child is at risk by being a danger to self or others, that is, is in a psychotic state. The primary focus of residential treatment is to create a therapeutic living environment that safely contains the child. During hospitalisation, the intervention by the whole multidisciplinary team can take place before the child returns home. The role of the occupational therapist in this environment will vary depending on the overall policy of the unit, the treatment approach of the multidisciplinary team and the facilities available. The child should always be assessed and treated within the context of the family, the school and the community. A child never lives in a vacuum, even in disrupted or dysfunctional families. The environmental context is vitally important. A comprehensive assessment of all the physical, psychosocial and developmental aspects, including the attachment style, social interactions and survival strategies, need to be documented. The child’s self-worth, confidence and spontaneity need to be observed, together with his/her strengths and interests. Assessment of coping and learning skills at school needs collateral information. Anxiety, depression, mannerisms and odd behaviour need to be documented together with the context in which it happens. Assessment of the child should take place from the first moment seen, wherever it occurs. Clinical reasoning and clinical observations give the most important information regarding children and their interaction with their environment and their family. It is often interesting and important to compare clinical reasoning with factual verbal information from collateral sources as these may not concur. The child’s behaviour, manner of talking, emotional expression and style of social interaction may differ in different situations, so observation in the home, school and at play is important. Introductions to the occupational therapist, play area and explanations need to be done by talking to the child on their eye level to form a relationship of trust. With younger children, the caregiver may need to be present, but sometimes, the child may act out or be reticent to talk. Often, parents tend to interfere and speak for the child, so an individual session with the child is preferable. The withdrawal of the caregiver or parent gives invaluable information regarding separation anxiety responses and the child’s sense of independence. An informal interview with the caregiver gives the child a chance to explore the environment. This free exploration time gives information about intrinsic motivation and curiosity. Care must be taken not to talk about the child’s problems in front of the child; rather use pen and paper to describe the behaviour or speak again to the carer later. Clinical observations must include the appearance and hygiene of the child, any scarring or injuries that may be from abuse or self-injurious behaviour and the postural background movements (restlessness or lethargy). Observation of his/her receptive and expressive language should include verbal and non-verbal communication, expressive articulation, speech regression or abnormalities, stuttering or stammering, pressure of speech or selective mutism. Body language together with speech may indicate withdrawal, depression, anxiety or defiance. When assessing gross and fine motor tasks should be used alternately, and throughout the session, sensory integration should be assessed. Tactile and other sensory defensiveness is cumulative so it may not be apparent at the beginning of the session. Throughout the assessment information needs to be gathered and documented to allow clinical reasoning to be holistic and have a meaning attribution regarding the behaviour observed. A cluster of behaviours or symptoms need to be present to formulate a problem area, not just an isolated incident or behaviour. When working as a member of a diagnostic or treatment team or single-handed at grass-roots level in the community, the occupational therapist must become an expert in observational skills. An ‘activity observation guide’ and a ‘social behaviour observation guide’ can be found in Parham and Fazio, Play in Occupational Therapy for Children (2008). The observations look at the intrinsic aspects of the child, the effects of the family and others and the greater community in which he/she lives. This is a developmental sequence of socialisation. Thus, a child lives in a matrix within the community, and these dimensions of the matrix need to be considered when observing the child. The tacit dimensions of the child’s behaviour are much more significant than that which is explicitly observed, namely, the underlying meaning of the behaviour. The child needs to be observed in relation to his/her developmental, occupational, emotional, behavioural and social abilities. The assets (abilities) and challenges (disabilities) related to his/her normative developmental age need to be assessed, but the use of the Model of Creative Ability (du Toit 1991) to place a child on his/her creative participation level is also essential. This aids in appropriate activity selection so that the selection of activities motivates participation. This is a far better guide than using age-appropriate/developmentally appropriate activities, especially with children who are psychiatrically ill or those who are depressed and demotivated (Table 16.1). Table 16.1 Vona du Toit (1991) model of creative ability applied to paediatrics (Alers in Crouch & Alers 2005). Assessment reports and progress reports show the quality of the occupational therapist’s observations, clinical reasoning and insight into the child’s responses to his/her environment. It is important to be succinct and holistic. When working with the family, especially in the community setting, it is imperative to discuss the child’s strengths and weaknesses with the caregivers and to assist them in accepting the child as a worthy person within the family. Often, the child is rejected, ridiculed and belittled, thus exacerbating the psychiatric illness. A cluster of behaviours or symptoms need to be present to formulate a problem area, not just an isolated incident or behaviour. Observe behaviour which will denote symptoms of stress and anxiety such as fears, phobias, separation anxiety, ‘clowning’, ‘baby talk’, poor self-esteem, tics, self-destructive or attention-seeking behaviour and tantrums, hypochondriac or psychosomatic symptoms, tactile defensiveness and hyper-vigilance. Behaviour also relates to the child’s attachment style (Crittenden 2013). Collateral information is necessary to ascertain whether the child lies, steals, fights, bullies or is bullied, disobeys instructions, starts fires, destroys toys and articles, acts out aggressively or quarrels frequently or hurts others (biting, pinching). The child’s response to teasing and frustrations gives insight into his/her coping strategies. Risky behaviour in the older child needs careful analysis of the cause. Hyperactivity, under-activity or withdrawal needs to be described in context. Notice poor coordination, poor postural background movements and lowered muscle tone. Observe for dyspraxia or overt acting out. The child’s ability to modulate his/her motor behaviour gives an indication of his/her intrinsic motivation. Poor concentration, distractibility (intrinsic or extrinsic) and preoccupation with an object or subject indicate the attention and arousal level of the child. Daydreaming and dissociation indicate a need to escape to his/her own world due to anxiety or a low arousal level. Play in a formal and informal way (in the playground) needs to be observed. The child’s choice of play, constructive or destructive approach, social interactions and use of objects give an indication of how the child sees his/her world. The choice of older or younger friends, especially in adolescence, may indicate maturity and a need for acceptance. Spontaneity, anxiety and playfulness are well described in Parham and Fazio (2008). The content and context appropriateness of speech needs to be noted. Stuttering, stammering, oral praxis and pressure of speech, together with receptive and expressive language, need to be assessed throughout the session. Selective mutism needs to be noted and observations made of the context in which it happens. The intrinsic motivation for the child to participate in creative or drawing activities shows the degree of self-confidence and spontaneity present. The task concept and completion of activities are seen together with frustration tolerance. These habits may be used to self-soothe or to self-stimulate. Thumb sucking, nail biting, body rocking, twirling, head banging, hair pulling and any self-injurious behaviours need to be documented. Inappropriate sexual behaviour may be shown with abused children or as a physiological calming behaviour (masturbation). Disinhibited seductive behaviour may be indicative of seeking acceptance. Conflicts about sexual identity will emerge when a trusting relationship has been developed. Observe whether the child is anxious, depressed, elated, preoccupied, apathetic, hostile and displaying feelings of guilt or has mood swings. Notice whether the mood and posture are congruent. Collateral information about the resultant effect on the family, especially the caregiver, needs to be obtained.
Occupational Therapy Intervention with Children with Psychosocial Disorders
Introduction
Attachment theory: A critical domain of concern
The assessment
Motivation level
Action level
Key components
Tone
Pre-destructive
Birth to ±5 months
Movements are irregular and uncoordinated
Survival responses for needs to be met by the caregiver
Dependent on caregiver
Self-differentiation
Destructive
±5 months to ±9 months
Sensory experiences are the primary activity focus (feeling, rubbing, chewing, biting, tasting, looking)
Child throws, tears and pulls at objects
Starts to recognise parents, smile responses. Communication is mostly receptive
Self-differentiation
Incidental
10 months to ±2 years old
Aware of self as an entity (separate from mother and environment)
Interaction is short-lived (1 step) and outcomes are unplanned and immediate
Objects are manipulated more (holding, placing or rubbing) but no tool handling or skill
Repetitive movements
Communication is limited. Responds to ‘known’ people. Limited expressive vocabulary, one-word sentences
Self-presentation
Explorative
±2 years to ±5 years old
Starts to control interaction with environment
Materials are explored to determine its properties
Products still largely unplanned, but with step-by-step approach, 4–5-step product can be successfully made. No norms of quality/speed
Develop a task concept, and tool manipulation is explored and tested
Development of basic concepts occurs
Explores social boundaries. Seeks approval from others. Communication now two way but more for the child’s benefit (egocentric). Does not fully understand situations and oblivious to the subtleties of body language and innuendo
Fantasy play and role modelling are enjoyed
Passive participation
Experimental
Schoolgoing child (pre-school and primary)
Interaction is product centred with a consolidated task concept, but external motivation/stimulation still required. Step or sequence prompting occasionally required
Tool handling is more product centred, and practice leads to some levels of skill
Product evaluation is a need of the child, but negative evaluation is not well accepted
Active learning, but not self-directed. Do not like to participate in unfamiliar situations. More comfortable in familiar situations and sequences previously experienced. Practice
Relationships are less dependent and more self-maintained. Development of peer acceptance and norming is a focus, but selected peer groups may vary frequently
Imitative participation
Imitative
Early adolescent
Task participation is product centred and self-fulfilment orientated, but initiative still limited
Experienced at a variety of tool and material handling
Works well from a model, and evaluation of performance becomes comparative instead of quality centred
Socially conforming. Tries to imitate (be identical) the peer group in all spheres of life. Susceptible to peer pressure
Behaviour is acceptable/appropriate to most situations
Behaviour
Conduct
Motor behaviour
Attention span
Play
Language
Activities
Habitual manipulations
Sexual behaviour
Mood
Relationships with other children
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Specific Occupational Therapy Intervention with Adolescents
The Treatment of Eating Disorders in Occupational Therapy
Sensory Integration in Mental Health
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