18
PSYCHOSOCIAL TREATMENTS
The ideal mental health service delivery system provides a continuum of care (i.e., integrated programs at all levels of intensity) in which the child and family can move easily from one service to another as the clinical situation warrants.
Child and adolescent psychiatric disorders cannot be successfully treated unless the family dynamics and the school environment are considered. The parents are always involved, at a minimum to ensure coordinated treatment and to remove any secondary gain that inadvertently maintains the child’s symptoms. For many disorders, therapeutic work with the parents or the family is just as important, or even more important, than direct therapy with the child. Often, the therapist coordinates with the school, the pediatrician, a social welfare agency, juvenile court personnel, and/or a community recreation leader. Whatever the modalities of therapy used, the therapist must be aware of the patient’s level of physical, cognitive, and emotional development in order to understand the symptoms, set appropriate goals, and tailor effective interventions. A focus on the skills necessary for successful development and adaptation, with attention to improving those at which the child or parent is not sufficiently competent, may facilitate successful therapy.
In the outpatient setting, treatment by a single therapist is generally most efficient and effective. Indications for collaborative treatment (two or more therapists working as a team) include an adolescent who is unusually concerned about confidentiality, the need for different types of skills that one therapist does not have, or a clear need of the patient and parent(s) for different qualities in a therapist (e.g., the child would benefit from a male role model, but the mother has great difficulty relating to men). In collaborative treatment, the therapists must maintain free and open communication, discuss and agree on treatment plans, and avoid aligning into competitive “teams.” Unresolved conflicts over relative power and authority of the therapists will lead to difficulties in treatment.
Therapists must maintain clear guidelines for confidentiality and for relaying information between the parent and child. Adolescents are usually more sensitive to this issue than children. In general, the therapist should tell each party when and what information from his or her session will be relayed to the other. Parents and children may participate in the decision or in the communication itself. When children or adolescents are engaging in potentially dangerous activities or have serious thoughts of harming themselves or others, parents must be informed. Carefully planned joint parent–child sessions, in which the therapist coaches and supports the parent or child in sharing information, may be more useful than reports from the therapist.
Recommended books and chapters in “Additional Reading” offer guidance in implementing psychosocial treatments.
COMMUNICATION WITH CHILDREN AND ADOLESCENTS
Children’s ability to use language is limited by their cognitive immaturity. Young children often use play to express feelings, to narrate past events, and to work through trauma. In play therapy, the therapist uses the metaphor of the child’s symbolic play and bases questions and comments on characters in the play rather than focusing directly on the child’s own feelings and experiences (even if the connection is clear to the therapist). The skilled therapist tailors communication to the child’s stage of language and cognitive development and must be aware that the vocabulary of some bright and precocious children exceeds their emotional understanding of events and concepts. Dramatic play with dolls or puppets; drawing and other art techniques; and questions about dreams, wishes, or favorite stories or television shows can provide access to children’s fantasies, emotions, and concerns.
THE RESISTANT CHILD OR ADOLESCENT
It is not surprising that many children and adolescents do not wish to engage in therapy. Treatment is typically sought for them by parents or teachers. Many children and adolescents do not perceive a reason for them to change; they view that as “giving in” to parents or teachers. A wide variety of motivations may lead a child or an adolescent to refuse to participate in or attempt to sabotage therapy. It is important to understand the patient’s viewpoint and agenda and tailor resistance-reducing strategies to the cause. A child who is anxious or having difficulty separating from a parent may be helped by having the parent initially present in therapy. The therapist may address, either directly or through play, the patient’s reluctance to participate and may suggest possible causes that the child is unwilling or unable to verbalize. Long silences in therapy are generally not helpful and tend to lead to increased anxiety or struggle for control. Attractive play materials help to make the therapy situation less threatening and encourage participation while the therapist builds an alliance. Even adolescents often appreciate the availability of paper and markers. Play can be combined with therapy in techniques such as storytelling, drama, and specially designed games. The therapist must guard, however, against the sessions becoming only play or recreation instead of therapy. Use of a token economy (i.e., rewards for desired behavior and loss of rewards for disruptive behavior; see below) in the therapy situation may improve motivation, especially for materially deprived or oppositional children.
TYPES OF PSYCHOTHERAPY
The common themes of individual therapies are listed in Table 18–1
A relationship with a therapist who is identified as a helping person and who has some degree of control and influence over the patient |
Instillation of hope, pride, and improved morale |
Use of attention, encouragement, and suggestion |
Goals of helping the patient to achieve greater control, competence, mastery, autonomy, and coping skills |
Goals to abandon or modify unrealistic expectations of self, others, and the environment |
Source. Adapted from Strupp 1973. |
Supportive Therapy
Supportive therapy may be especially useful for children and adolescents who do not have satisfying relationships with adults because their symptoms make it very difficult to establish a positive relationship or their parents are emotionally or physically unavailable, or even hostile. For the patient in crisis, the therapist provides support until a stressor resolves, a developmental crisis has passed, or the patient or environment changes sufficiently that other adults can take on the supportive role. The patient has a real relationship with the therapist, who facilitates catharsis and provides understanding and judicious advice. Psychoeducation is often included in supportive therapy.
Psychodynamically Oriented Therapy
Psychodynamically oriented therapy is grounded in psychoanalytic theory but is more flexible and emphasizes the real relationship with the therapist, the provision of a corrective emotional experience, and the experience of transference. Goals include resolution of symptoms, change in behavior, and resumption of the normal developmental process. Mechanisms of change include understanding and working with transference feelings, catharsis, development of insight, strengthening of ego skills and adaptive defenses, and improvement in reality testing. The therapist forms an alliance with the child or adolescent, identifies feelings, clarifies thoughts and events, makes interpretations, judiciously gives information and advice, and acts as an advocate for the patient. Sessions are held once or twice a week.
Possible candidates for psychodynamically oriented individual therapy include verbal youngsters (or those who can use symbolic play) who are in significant emotional distress or who are struggling to deal with a stressor or traumatic event (e.g., parental death, divorce, or abandonment; physical illness). Patients with attention-deficit/hyperactivity disorder (ADHD) or disruptive behavior disorders are unlikely to benefit. Youngsters with ADHD have little insight into their behavior and its effect on others and may be genuinely unable to report their problems or to reflect on them. Patients with oppositional defiant and conduct disorders refuse to acknowledge problem behavior and are better treated in family or group therapy or in a structured milieu.
Time-Limited Therapy
All of the models of time-limited therapy have in common a planned relatively brief duration (several sessions to 6 months), a predominant focus on the present, and a high degree of structure and attention to specific, limited goals. Theoretical foundations of various models include psychodynamic, crisis, family systems, cognitive, behavioral or social learning, and guidance or educational. Both the therapist and the patient must take active roles. The short duration is used to increase patient motivation and participation and limit nonadaptive dependency and regression. A great deal of attention is paid to the process of termination and to how the patient will continue to make progress after therapy stops. Psychodynamic models emphasize a firm termination of therapy, while cognitive, behavioral, and supportive models often include periodic “booster” sessions.
Time-limited treatment appears to be at least as effective as longer-term therapy for some patients. Time-limited methods have been recommended for multiproblem, crisis-oriented families who are unlikely to persist in longer-term treatment and for well-functioning children and families with circumscribed problems of recent onset. Brief treatment is relatively contraindicated for long-standing severe problems and for children and adolescents who have endured serious losses and/or deprivation.
Other Models of Therapy
Specific structured therapy programs and techniques have been developed and tested for a variety of pediatric psychiatric disorders and symptoms (see “Additional Reading”). These techniques may be used individually or in diagnosis-specific groups. Parents may be included in psychoeducation, support, implementation of strategies at home, and/or interventions for their own symptoms, to improve outcome for the youth.
Cognitive-Behavioral Therapy
Manualized cognitive-behavioral therapy (CBT) techniques have been developed and adapted for children and adolescents with many disorders, including depression, obsessive-compulsive disorder, anxiety disorders, and bulimia nervosa. These empirically supported techniques may be used individually, in diagnosis-specific group therapy settings, or in family based treatment (see Beidel and Reinecke 2016; Szigethy et al. 2012 in “Additional Reading”). There is also an evidence-based model of trauma-focused CBT for youth (see Cohen et al. 2017 in “Additional Reading” and www.musc.edu/tfcbt).
CBT encompasses a range of techniques used to target specific symptoms. The key components include exposure and response prevention (a hierarchy of feared situations is gradually and successfully approached with graduated exposures), cognitive restructuring (recognition of negative thought processes that are then challenged and replaced with more realistic and positive self-statements to improve emotional/behavioral responses to situations), relaxation training (reducing arousal by progressive use of relaxation exercises or cognitive meditation techniques), pleasant activity scheduling or behavioral activation (particularly for patients with anergy, anhedonia, lack of motivation, or social isolation), and problem-solving skills (exercises to sequentially examine problems, goals, and possible solutions, with selection of an agreed-upon strategy to employ and subsequent self-evaluation of the results). Parents and caregivers can play a critical “coaching” role for CBT assignments between sessions and their collaboration is essential in psychoeducation and treatment planning.
Interpersonal Psychotherapy
Interpersonal psychotherapy for depressed adolescents (IPT-A) (see Gunlicks-Stoessel and Mufson 2016; Mufson et al. 2004 in “Additional Reading”) was developed as a time-limited psychotherapy based on the work of interpersonal theorists and developmental adaptation from the interpersonal psychotherapy (IPT) as used with adults. The IPT model focuses on the premise that depression occurs within an interpersonal framework. IPT serves to relieve symptoms of depression by improving communication patterns, which then positively influence relationships, thus improving depression. IPT also incorporates attachment theory by addressing interpersonal conflicts, transitions, and grief in the context of relationships. IPT-A was designed as a 12-week treatment for nonpsychotic depressed adolescents. It has been used when comorbidities exist, although it is most effective when depression is the primary diagnosis and comorbidities are minimal. Parental participation is recommended.
Motivational Interviewing
Motivational interviewing has its roots in the work of Carl Rogers on client-centered therapy. It is particularly useful with patients who do not come to treatment of their own accord, such as adolescents who abuse substances. The basic principle is that if a person experiences a safe, comfortable, and collaborative therapeutic environment, he or she will be more likely to participate with the therapist to acknowledge and examine his or her problems and make progress toward their resolution. Techniques deal explicitly with patient resistance and ambivalence to enhance motivation and willingness to consider change in behavior (see Nagy and Armstrong 2016 in “Additional Reading”).
Dialectical Behavior Therapy
Dialectical behavior therapy (DBT), based on the theoretical and empirical work of Linehan with adults suffering from borderline personality disorder, has been developmentally extended to work with suicidal adolescents and those who engage in nonsuicidal self-injury (see Miller et al. 2007 in “Additional Reading”). This approach (DBT-A) combines creative individual, family, and group therapy and skills training seminars from a variety of conceptual frameworks with telephone-based coaching and crisis intervention and group consultation for therapists in the treatment of this very difficult and crisis-prone population.
PARENT COUNSELING AND PSYCHOEDUCATION
Parent counseling or guidance is primarily an educational intervention, conducted with individual parents or couples in groups (see Mendenhall et al. 2016 in “Additional Reading”). Parents learn about normal child development. The therapist helps parents to understand their child and his or her problems and to modify parental attitudes and behaviors that seem to be contributing to the difficulties. The therapist must try to understand the parents’ point of view and to be sympathetic to the hardships of living with a troubled child or adolescent. For parents who have serious difficulties of their own, parent counseling may merge into or pave the way for marital therapy or individual treatment of the adult.
Virtually all parents of children with psychiatric or learning problems need and deserve education on the nature of their child’s disorder and how to select among treatments and manage difficult behavior. Parents spend far more time with their children than the therapist does and can powerfully assist or impede treatment. Parents of children with chronic problems must become skilled advocates, to ensure that their children receive the treatment and schooling that they need. Carefully selected reading material (“bibliotherapy”) or Web sites may be extremely useful to parents (see Appendix, “Resources for Parents”).
BEHAVIOR THERAPY
Behavioral therapists view symptoms as resulting from habits, faulty learning, dysfunctional interaction patterns, or neurodevelopmental deficits, rather than from unconscious or intrapsychic motivation.
In an operant approach, positive and negative environmental contingencies (responses to the child’s behavior) are identified and then modified in an attempt to decrease problem behaviors and increase adaptive ones. A token economy, one type of operant approach (see below), can be used successfully by parents, teachers, therapists (with groups or individuals), and staff of inpatient or day treatment programs.
Social learning theory integrates operant conditioning theory with an understanding of cognitive processes and emphasizes the importance of learning new behaviors by observing or imitating others. For example, modeling is used in the treatment of children’s anxiety and fears to decrease social withdrawal and teach adaptive skills.
Behavior therapy is commonly used to reduce symptoms of ADHD, oppositional defiant disorder, and conduct disorder. Central to assessment and treatment planning is a functional behavior analysis that evaluates the “ABCs” of problem behaviors—that is, the antecedents, the behaviors themselves, and the consequences, intended or not, of the behaviors. This often illuminates ways in which children and adults may both have a role in triggering and maintaining the problem behaviors and suggests strategies for modifying the interactions and the behaviors.
Parent Management Training
Parent management training may be done with individual families or in groups. Programs have been developed for families of young children, older children, and adolescents (see “Additional Reading”). Families begin by charting targeted behaviors and their antecedents and consequences. Initial treatment goals should focus on a limited number of target behaviors with which families are likely to achieve early success. As family members gain skills and reach goals, more complex or difficult behaviors are approached. Teaching techniques include written and verbal instruction in principles of social learning and behavior modification, modeling by the therapist, behavioral rehearsal of skills to be used, and homework assignments with subsequent review, feedback, and repetition.
Children with disruptive and noncompliant behavior often elicit high levels of negative attention from the adults in their lives, while their appropriate behavior often goes unnoticed. The parent–child relationship may have become strained or antagonistic. A first step in parent management training is to emphasize and teach how to reinforce positive behaviors with attention, praise, or other positive reinforcers. Parents are encouraged to devote at least brief periods of time to child-directed activities without questioning or redirection. Parents are also advised to ignore mild forms of misbehavior. Once these habits are established, the problematic behaviors are addressed using a reward system or token economy in which a child can earn tokens or points for positive behavior which they can later cash in for positive reinforcers (rewards). As the child masters the behaviors, the rewards can be gradually faded (reduced in frequency) or transferred to another behavioral target. Punishment generally should be brief, proximate to the misbehavior, and consistently enforced. Time out, which puts the child in a quiet, boring area where he or she experiences a “time-out” from accidental or naturally occurring positive reinforcement, is an effective punishment if properly applied, especially for younger children. Some parent management programs also address parental stress and parental cognitions about their children and their behaviors. These interventions help parents stay calm and rational rather than escalating negative situations.
Treatment is most effective for young children and those with less severe and persistent behavior problems. Characteristics that have been associated with less positive outcome in parent training include low socioeconomic status, parental psychiatric problems, marital conflict, lack of a social support network, harsh punishment practices, and parent history of antisocial behavior (Kazdin 1997). Families with these characteristics should receive maximally potent interventions, with attention to the parents’ individual or marital problems as necessary. Additional topics may need to be addressed, such as skills for resolving marital conflict or managing parental anger. More highly functioning families may be able to succeed with written materials only or by using manuals or videotapes supplemented by group discussion. The therapist must be aware of ethnic and cultural beliefs and customs regarding child development and parenting.
Behavioral intervention can be done in the context of family therapy, including techniques such as parent–child contingency contracting. A social contract is written that specifies the behaviors that the parent and child will change, with contingencies. The family is trained to negotiate and solve problems. These techniques may be particularly useful for adolescents.
Classroom Behavior Modification
Techniques for use in schools include class rules, attention to positive behavior, token economies, and response-cost programs (reinforcers are withdrawn in response to undesirable behavior). The teacher may dispense simple reinforcers such as praise, stars on a chart, or classroom privileges, or parents may provide positive reinforcement and/or response cost based on a “daily report card” that the teacher sends home, rating the child’s performance that day on selected target behaviors (Kelley 1990).
FAMILY-BASED ASSESSMENT AND TREATMENT
Role of the Family in Treatment
Attempts to treat disorders in children or adolescents without considering the persons with whom they live or have significant relationships are doomed to failure. Change in one family member, whether as a result of a psychiatric disorder, psychiatric treatment, normal developmental process, or life events, will affect other family members and their relationships. Family constellations vary immensely, from the traditional (but increasingly rare) nuclear family to grandparents functioning as parents, a single-parent family (with or without contact with a second parent), a stepfamily, or an adoptive or foster family. The term parents refers here to adults filling the parenting role regardless of their biological or legal relationship to the patient.
Supportive therapy with families includes counseling in methods of changing behavior; encouraging more positive and realistic parental feelings and attitudes toward children; helping family members to manage their emotional reactions to the child’s psychiatric disorder; detecting and obtaining treatment for psychiatric disorders in parents and siblings; and advising parents about schools, treatment modalities, community or leisure activities, and sometimes complex custody and placement decisions.
Family Therapy
Indications
There is empirical support for the effectiveness of family-based interventions (see Wendel and Gouze 2016 in “Additional Reading”) as the primary or adjunctive treatment for behavior problems (including adolescent substance abuse), depression, bipolar disorder, anxiety, and eating disorders.
Family therapy may be particularly useful when dysfunctional interactions or impaired communication within the family appear to be related to the presenting problem or when symptoms begin or worsen with a new developmental stage or a change in the family such as divorce, remarriage, adoption, or foster placement. If more than one family member has symptoms, family therapy may be more efficient and effective than multiple individual treatments. It should be considered when one family member improves with treatment but another, not in treatment, worsens. Cases in which the identified patient is relatively unmotivated to participate or to change are likely to be more successful in family therapy than in individual therapy. Attention to family systems issues may be useful when progress is stalled in individual therapy or in behavior therapy. Often family therapy is part of a multimodal treatment plan.
If patients have clearly organic physical or mental illness or if the family equilibrium is precarious and one or more family members are at serious risk for decompensation, family therapy may be useful as an adjunct to other treatments, such as medication or hospitalization. A patient who is acutely psychotic, violent, or delusional regarding the family should not be included in family therapy sessions. Family sessions may not be helpful when a parent has severe but unworkable psychiatric disturbance or when the child or adolescent strongly prefers individual treatment. Children should not be included in family sessions when parents continue (despite redirection) to criticize them or to share inappropriate information, when the most critical issues are marital, or when parents primarily need specific concrete help with practical affairs or parent training. Cultural sensitivity and competence are even more important when working with families than with individuals.
Types of Family Therapy
Structural family therapy (developed by Minuchin) has been the model most used and studied in families in which a child or an adolescent is the identified patient. Its focus is on the present; the identified patient’s symptoms are seen as serving a function for the family. The assessment process includes mapping the structure of the family, including the location and permeability of boundaries between family members and around the family and its subsystems. Other important variables are the character and flexibility of alignments of family members, including alliances (joining two or more members in a common interest or task) and coalitions (joint actions directed against one or more family members). Data are gathered on communication patterns and the distribution of power within the family and on the family’s sources of stress and support in the environment.
The therapist uses assigned tasks and his or her own interactions with family members to influence the family to change its structure and thereby its functioning, resulting in resolution of the presenting symptoms. Relabeling (i.e., redefining a behavior or symptom to give it a different, usually less negative, meaning for the family) opens alternative pathways for family interactions.
Other types of family-based interventions are used for specific circumstances, such as family grief therapy, in-home family preservation services, infant or toddler–parent interactive psychotherapy, and family approaches for chronic physical illness. Models that have been used to treat conduct disorders include Patterson’s behavioral family therapy; Alexander’s functional family therapy, which combines behavioral and family systems theories and techniques with attention to cognitive processes; and multisystemic therapy, developed by Henggeler and Borduin (see “Additional Reading”), which uses various home-based therapeutic techniques (family therapy, parent training, and cognitive-behavior therapy) along with direct practical assistance to the family in the context of the adolescent’s natural environment of home, school, and neighborhood. For eating disorders, Maudsley family therapy is used (see Chapter 10, “Feeding and Eating Disorders”).
Psychoeducational family therapy, initially developed for families of adults with schizophrenia, has been extended to families of patients with childhood disorders, such as eating disorders, ADHD, and anxiety and mood disorders. Detailed didactic presentations about the disorder are designed to enhance the family’s support networks and to improve the family’s coping skills through increased understanding of the illness, its treatment, and home behavior management techniques. Ongoing treatment uses family systems interventions when educational and behavioral techniques are blocked by maladaptive family structures or processes. Multiple family group interventions are also used in outpatient treatment programs for various disorders and for families of patients in inpatient or partial hospitalization programs.
GROUP THERAPY
Indications
Group therapy may be particularly useful for children and adolescents, who are more willing to reveal their thoughts and feelings to peers than to adults. It also offers the clinician an opportunity to observe in vivo patients’ interpersonal skills and interactions with peers and allows patients to observe and practice important social skills and to benefit from peer companionship and support. Feedback and input from peers may be given more credence than observations and suggestions from an adult therapist. Often target symptoms such as aggression, withdrawal, shyness, and/or deficient social skills with peers are not apparent or accessible to intervention in individual therapy. Group therapy can provide a powerful context in which to teach social skills and language, especially for children with autism spectrum disorder or developmental delays. CBT and IPT-A for depressed adolescents, CBT for anxiety disorders, and DBT can all be delivered in a group setting. Motivational therapy and twelve-step groups are used for adolescents who have problems with drug or alcohol abuse. Multifamily psychoeducational groups are often used for outpatients and on inpatient units or partial hospitalization programs. Support groups include members who share a common stressor (e.g., sexual abuse, parental divorce, a chronic physical illness, loss of a loved one). Other groups are specifically targeted to a single psychiatric disorder. Groups that focus on social skills work best with a mixture of patients.
Group psychotherapy is contraindicated for extremely fragile youth and those who are psychotic or paranoid. Adolescents with sociopathic traits or behaviors should not be included in groups with others who might be victimized or intimidated. Severely aggressive or hyperactive children should probably not be included in outpatient groups because of the difficulty in controlling their behavior, the risk of their modeling of problem behaviors for other children, and their intimidation of less assertive children.
Technical Considerations
All of the theoretical models used in individual therapy may be used in group therapy. Therapy may be exclusively verbal or may include expressive arts techniques (such as psychodrama, dance, or arts and crafts), sports activities, or behavioral techniques (such as anger management skills, modeling and practicing social skills, cooperation, and negotiation). Whatever the type of group, the therapist must understand the dynamics of group process. Psychoeducation and supportive treatment can be provided efficiently in groups.
Some groups have a defined, limited duration, from 6 weeks to an academic year; others are longer term. Therapy groups conducted in therapeutic schools, inpatient units, or day hospitals are typically open ended and often include all children enrolled in the program, with youth typically grouped by age. Special topic groups focusing on anger management and problem-solving skills, cognitive behavior techniques, substance use, social skills, abuse-related issues, or preparation for discharge from the program may also be offered.
Group members should be in the same or adjacent developmental stages. Children and adolescents change so dramatically as they develop that an age span broader than 2 or 3 years is likely to impede the therapeutic group process. When groups for pre- and early adolescents are being formed, developmental stage is often more important than chronological age. Early adolescent girls mature physically, emotionally, and socially more rapidly than same-age boys. If not taken into account when forming a group, this differential maturation, as well as individual differences in developmental trajectories, may negatively affect group dynamics.
Opinions differ on whether to include boys and girls in the same group. Some issues might be better handled in single-sex groups, although children and adolescents benefit from interactions with opposite-sex peers. Combining boys and girls, although initially more difficult, may ultimately be more productive, depending on the setting. In mixed-sex groups, efforts should be made to have approximately equal numbers of boys and girls. In adolescent groups, the leader(s) must be alert to possible sexual undercurrents and acting out, while facilitating the discussion of sexual concerns and the practicing of social skills.
Children with ADHD are often referred to group therapy because of their difficulty with peer relationships and their lack of insight into their difficulties. Children who are taking stimulant medication may need to receive a dose before the group meets to help them benefit from group therapy and not disrupt it for others.
Of all modalities of therapy, the need for co-therapists is most evident in group treatment. Groups are complex, with many events occurring simultaneously, and a second observer is valuable. In groups of younger children, an extra pair of hands is often needed. Co-leaders who differ from each other in age, sex, race, or culture may expand the opportunities for different types of patient–therapist relationships. The group structure should fit the nature of the group and the patients. The leaders are responsible for maintaining structure and control of behavior within the group. The leaders must be explicit about the rules of confidentiality for the group because the group setting increases the risk of breach of confidentiality.
For younger children, games and craft activities can provide a useful structure, but the leader(s) must ensure that recreation does not become the only function of the group. Behavior modification, cognitive problem-solving techniques, and anger management skills may be employed. Many child and adolescent patients will not spontaneously attempt to relate to other children. Others have been rejected, bullied, or scapegoated by peers. If the group therapy is successful, the patients will be able to generalize the skills learned in the group to form relationships with peers at school and in their neighborhoods.
Parental involvement is especially crucial for preschool- and school-age children because parents can provide valuable information regarding important events in the child’s environment and treatment progress outside of the group setting. Adolescents are better able than younger children to report on external events and progress. They are also more sensitive to confidentiality issues; thus it may be advisable to keep parents more distant from the content of sessions. For children of all ages, the therapist should inform parents of the general goals of the group and their child’s progress toward specific goals. Parent education in development and behavior management is often effectively provided in a coordinated parent group session. Parents may also appreciate the opportunity to meet with other parents whose children have similar problems.
SYSTEMS OF CARE
Innovative community services, often called “wraparound” programs, are used to avoid hospitalization or placement in residential treatment. Such services attempt to address complex needs (psychological, school, family, peer, spiritual) in a strength-based community model. Wraparound services involve a variety of interventions with individualized programming and therapy, active involvement of family and community members, integration with social services (such as child welfare, financial support, and housing), as well as the educational and justice systems; and use of interventions in the home, neighborhood, community, and school rather than in the traditional office or hospital setting. Crisis intervention teams, brief respite placement, and in-home therapy/supervision are typically included. Funding sources vary depending on the specific community or state.
MILIEU TREATMENT: INPATIENT HOSPITALIZATION, RESIDENTIAL TREATMENT, AND PARTIAL HOSPITALIZATION
Inpatient Hospitalization and Residential Programs
Indications
Because children and adolescents should be treated in the setting that is least restrictive and disruptive to their lives, hospital or residential treatment is reserved for youngsters who have not responded to outpatient treatment due to severity of symptoms, lack of motivation, or severe disorganization of the patient or family. If there is concomitant physical illness requiring skilled medical/nursing care, pediatric hospitalization may be necessary. In cases where the family’s presentation for psychiatric services has been delayed, symptom severity may require more intensive treatment from the outset, even before outpatient services are attempted.
Inpatient hospitalization is usually an acute event that is precipitated by immediate physical danger to self or others, acute psychosis, a crisis in the environment that reduces the ability of the caregiving adults to cope with the child or adolescent, or failure of less intensive forms of treatment. Hospitalization may be needed for a more intensive, systematic, and detailed evaluation and observation of the patient and family than is possible in an outpatient or a day treatment program or if the patient is resistant to outpatient or day treatment. Most hospital lengths of stay are very short (i.e., 5–10 days). With exceptions only for the most severely ill children and adolescents (or those unfortunately awaiting residential placement), hospitalization is now typically used only to stabilize the acute clinical situation and to arrange for treatment in a less restrictive setting. Placement in a residential treatment center may be indicated for children and adolescents with chronic behavior problems such as aggression, running away, truancy, substance abuse, school refusal, or self-destructive acts that the family, foster home, and/or community cannot manage.
Components of Treatment
Pharmacotherapy. Hospitalization offers an opportunity for trials of medications in children or adolescents whose conditions have not responded to previous treatment, who have complicated or unclear diagnoses, who have medical problems complicating pharmacotherapy, or whose parents are not able to reliably administer medication and report on efficacy and side effects. Resumption of previously prescribed, but not reliably taken, medication is often needed.
Individual psychotherapy. As newer treatment methods have evolved and hospital stays have become shorter, individual psychotherapy is less often used as an inpatient primary treatment modality. Regularly scheduled individual sessions with a therapist with whom the child or adolescent can develop a trusting relationship continue to be important in developing a more thorough understanding of the patient’s developmental status and intrapsychic, familial, and social dynamics and assisting him or her to develop more adaptive methods of coping with strong emotions. The therapist may be able to help the patient better understand his or her own difficulties and benefit from the other treatments offered. In a short hospital stay, the patient’s trauma history may become apparent, but addressing traumas and losses is deferred to longer-term therapy.
Milieu therapy. Milieu therapy encompasses the entire treatment environment, including interactions with staff outside of scheduled therapy sessions. The 24/7 setting offers a valuable opportunity to observe the patient during meals, sleep, self-care, and play. Milieu structure provides clear rules and a regular routine to promote a sense of security and predictability as well as teaching of specific skills to increase self-esteem and competence. Many settings include a behavioral program that uses a token economy or privilege level system to manage behavior and to modify specific symptoms.
Group therapy. In addition to general or special topic groups, many programs include therapist-led community meetings in which patients practice coping and social skills, and learn to observe their own and others’ behavior and to recognize the effect of their behavior on others.
Education. The majority of children and adolescents who require out-of-home placement have had problems in school. The small classes and highly trained teachers of a hospital unit or residential center can provide a detailed evaluation of a patient’s academic strengths and weaknesses. One of the most important components of discharge planning is arranging for an appropriate educational placement and working with the teacher to set appropriate target goals. Youth in residential treatment centers are gradually integrated into a special education or mainstream program in the local public or private schools, although some larger residential centers have their own school on campus.
Family treatment. Work with families is an essential part of hospital treatment. Interventions may include family therapy, parent counseling in behavior management, and education about the nature of the child’s disorder and treatment plan. Parents may require marital therapy; referral for individual assessment and treatment; or help with housing, finances, day care, or medical care.
Partial Hospitalization
A partial hospitalization program (PHP), also known as a day treatment program, may be best for those children or adolescents who require more intensive intervention than can be provided in outpatient visits but who are able to safely stay at home, in foster care, or in a group home. Patients who are at immediate risk of serious self-harm or harm to others would not be appropriate for a PHP and require an inpatient level of care. Compared with hospitalization or residential placement, day treatment is less disruptive to the patient and the family and can offer an opportunity for intensive work with parents, who typically attend the program on a regular basis. Daily planning and review of home management strategies enhance generalization and maintenance of gains made in treatment. A day program may be used to avoid the necessity of inpatient hospitalization; to aggressively address school refusal, psychiatric, and behavioral problems; or as a transition (“step-down”) for a patient who has been hospitalized.
Day treatment programs vary in design, treatment techniques, and patient populations, although all treat moderately to severely ill children and adolescents. Some programs provide a full 8-hour day, 5 days a week, and include a school program. Acute PHPs have typical lengths of stay of 1–3 weeks. Other programs, often called intensive outpatient programs (IOPs), meet in the late afternoon and evening hours (typically for 3 hours), after patients attend community schools, and on weekends, to facilitate parental attendance. Some agencies offer intensive summer day treatment programs or a therapeutic day camp. The modalities of treatment are variable but tend to be similar to those described for inpatient units; however, the staff-to-patient ratio is typically lower.
ADJUNCTIVE TREATMENTS
At times, an intervention that is not, strictly speaking, a psychiatric treatment may be recommended as part of a treatment plan. These could include spiritual, recreational, or extracurricular activities. These programs may be crucial to the child’s or adolescent’s well-being and the treatment of the psychiatric disorder, or they may encourage progress or improve level of functioning.
Special Education Placements
Modified school programs are indicated for children and adolescents who cannot perform satisfactorily in regular classrooms or who need special structure or teaching techniques to reach their academic potential. These programs range in intensity from tutoring or resource classrooms several hours a week, to special classrooms in mainstream schools, to public or private schools that serve only children and adolescents with special educational needs. Resources differ from community to community, but most have programs for youth with intellectual disability, for those with specific learning disorders (learning disabilities), and for those whose emotional and/or behavior problems require a special setting for learning. Classes are small, with a high teacher-to-student ratio and specially trained teachers. Vocational evaluation and education may be crucial, especially for adolescents.
Students who do not need a special education placement but who need accommodations to meet standard academic goals may benefit from a 504 plan. The 504 plan (which refers to the section of the Rehabilitation Act of 1973 that prohibits discrimination based on disability) can specify accommodations such as extra time for testing, testing in a low-distraction setting, preferential seating, or check-ins with teachers or counselors for students with psychiatric diagnoses such as ADHD or anxiety.
Child and adolescent psychiatrists may be part of the interdisciplinary team as consultants or in school-based health and mental health clinics. These programs efficiently provide coordinated medical and mental health care, although funding can be difficult to maintain.
A boarding school may be useful when a parent–child problem is unresponsive to treatment or an appropriate placement is not available in the home community. Some boarding schools have special programs for children with specific learning disorders or psychiatric disorders.
Recreation
Learning to perform a sport or skill competently may be an important adjunct to treatment for children and adolescents who lack positive relationships with peers or adults because of social isolation, withdrawal, or being ignored or actively rejected. Trained recreation therapists work in various psychiatric and community settings and focus on teaching adaptive leisure skills and improving interactions with peers. A relationship with an adult such as a Big Brother or Sister or a YMCA counselor or sports coach offers an opportunity to interact with a peer group under supervision and may provide support and build self-esteem until the child or adolescent improves enough to establish relationships independently. Some families employ a high school or college student one or more afternoons a week to teach the child social and play skills, develop a relationship with the child, and provide structured time. This method also gives parents a respite and an opportunity to spend time with their other children.
Day or overnight summer camps are potentially a very helpful experience. Some youngsters can attend regular camp, whereas others need a therapeutic camp program geared toward children and adolescents with psychiatric or medical problems.
Foster Care
Placement in a foster home may be needed when parents are unwilling or unable to care for their child. Indications are clearest in cases of physical or medical neglect or physical or sexual abuse. Some families may not be able to provide the appropriate emotional nurturance and supervision. Court intervention is required for placement. Foster care should be short term, until parents are rehabilitated or the courts decide that more permanent placement is needed. Unfortunately, child welfare agencies in many communities are overwhelmed, and children and adolescents may require advocacy with the appointment of a guardian ad litem attorney to facilitate return to parents, placement in a foster home or group home, or termination of parental rights to free the child for adoption, according to the conditions of the child and family. Children in foster care have higher rates of both psychiatric and physical disorders than do children in the general population (Turney and Wildeman 2016).
Children with severe behavior or physical problems or older adolescents who are difficult to place or maintain in foster or adoptive homes may be placed in group homes with trained staff. These programs vary in staffing and intensity of the treatment offered. Some resemble residential treatment, whereas others simply provide a supervised residence.
Parent Support Groups
Various groups that provide education and support for parents, as well as conduct fund-raising and advocacy for services, have been organized by parents with professional support. Examples are listed in the Appendix. Numerous local groups (many of which are affiliated with national organizations) focus on specific medical or psychiatric disorders or on more generic psychological problems of childhood. They can provide a powerful adjunct to more traditional professional services.
REFERENCES
Kazdin AE: Parent management training: evidence, outcomes, and issues. J Am Acad Child Adolesc Psychiatry 36:1349–1356, 1997
Kelley ML: School-Home Notes: Promoting Children’s Classroom Success. New York, Guilford, 1990
Strupp HH: Psychotherapy: Clinical Research, and Theoretical Issues. New York, Jason Aronson, 1973
Turney K, Wildeman C: Mental and physical health of children in foster care. Pediatrics 138(5), pii e20161118 Epub 2016 Oct 17 27940775
ADDITIONAL READING
Barkley RA: Defiant Children: A Clinician’s Manual for Assessment and Parent Training, 3rd Edition. New York, Guilford, 2013
Barkley RA, Robin AL: Defiant Teens: A Clinician’s Manual for Assessment and Family Intervention, 2nd Edition. New York, Guilford, 2014
Beidel DC, Reinecke MA: Cognitive-behavioral treatment for anxiety and depression, in Dulcan’s Textbook of Child and Adolescent Psychiatry, 2nd Edition. Edited by Dulcan MK. Arlington, VA, American Psychiatric Association Publishing, 2016, pp 973–991
Chorpita BF, Weisz JR: MATCH-ADTC: Modular Approach to Therapy for Children With Anxiety, Depression, Trauma, or Conduct Problems. Satellite Beach, FL, PracticeWise LLC, 2009
Cohen JA, Mannarino AP, Deblinger E: Treating Trauma and Traumatic Grief in Children and Adolescents, 2nd Edition. New York, Guilford, 2017
Greene RW, Ablon JS: Treating Explosive Kids: The Collaborative Problem-Solving Approach. New York, Guilford, 2006
Gunlicks-Stoessel ML, Mufson L: Interpersonal psychotherapy for depressed adolescents, in Dulcan’s Textbook of Child and Adolescent Psychiatry, 2nd Edition. Edited by Dulcan MK. Arlington, VA, American Psychiatric Association Publishing, 2016, pp 959–971
Henggeler SW, Schoenwald SK, Borduin CM, et al: Multisystemic Therapy for Antisocial Behavior in Children and Adolescents, 2nd Edition. New York, Guilford, 2009
McMahon RJ, Forehand RL: Helping the Non-Compliant Child: Family Based Treatment for Oppositional Behavior, 2nd Edition. New York, Guilford, 2003
Mendenhall AN, Arnold LE, Fristad MA: Parent counseling, psychoeducation, and parent support groups, in Dulcan’s Textbook of Child and Adolescent Psychiatry, 2nd Edition. Edited by Dulcan MK. Arlington, VA, American Psychiatric Association Publishing, 2016, pp 875–899
Miller AL, Rathus HK, Linehan MM: Dialectical Behavior Therapy With Suicidal Adolescents. New York, Guilford, 2007
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Poncin Y, Woolston J: Systems of care, wraparound services, and home-based services, in Dulcan’s Textbook of Child and Adolescent Psychiatry, 2nd Edition. Edited by Dulcan MK. Arlington, VA, American Psychiatric Association Publishing, 2016, pp 1007–1026
Szigethy E, Weisz JR, Findling RL: Cognitive-Behavior Therapy for Children and Adolescents. Arlington, VA, American Psychiatric Publishing, 2012
Terr L: Individual psychotherapy, in Dulcan’s Textbook of Child and Adolescent Psychiatry, 2nd Edition. Edited by Dulcan MK. Arlington, VA, American Psychiatric Association Publishing, 2016, pp 849–874
Webster-Stratton C, Herbert M: Troubled Families-Problem Children: Working With Parents: A Collaborative Process. New York, Wiley, 1994
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