General Principles For Psychotherapeutic Interventions In Children And Adolescents

INTRODUCTION Childhood and adolescent psychiatric disorders often go unrecognized in our country, despite this subpopulation constituting one of the largest segments of the whole population. Proper assessment and management of different psychiatric disorders at this age are of paramount importance, which will ultimately impact the course and outcome of the particular condition at later age.[1] Although medicines/drugs are required to treat many of these disorders, psychotherapeutic interventions remain a preferred choice for clinicians as well as for parents and family members. Assessing children and adolescents throws up multiple challenges to a treating physician. First, a child/adolescent may disagree with the parents or the doctor regarding the need for consultation or would not have come for the consultation in the first place. Second, the child/adolescent could have come for an entirely different problem, whereas the main problem remains unnoticed by the caregivers.[2] Moreover, children may report their symptoms but may not provide other details, such as duration and chronology of their symptoms. They may also hide the problem if it depicts them in a bad light or are embarrassing for them. Therefore, a clinician should gather information from multiple sources, i.e., the child, parents, teachers, and other caregivers. An elaborate history-taking by an astute clinician helps in proper case formulation and embarking upon a psychotherapeutic procedure.[2] There can be discrepancies in the report; nevertheless, multi-source information minimizes error in diagnosis and management. Psychotherapy is a form of psychiatric treatment that involves therapeutic conversations and interactions between a therapist and a child or family. It can help children and families understand and resolve problems, modify behavior, and make positive changes in their lives. The term “psychotherapy” usually includes supportive, re-educative, and psychoanalytic forms of psychotherapy. All can be used to treat child and adolescent psychiatric disorders depending on the kind of problem we encounter in clinical practice. Various forms of psychotherapy that are used in the treatment of child and adolescent psychiatric disorders include acceptance and commitment therapy, cognitive behavioral therapy (CBT), dialectical behavior therapy, family therapy, group therapy, Interpersonal Therapy (IPT), mentalization-based therapy, parent–child interaction therapy, play therapy, and psychodynamic psychotherapy. Before we embark on a psychotherapeutic engagement with a child or adolescent, we must be very sure regarding the nature of the problem at hand and what exactly we need to address or which behavior we want to modify. Parents also at times come up with unusual demands which are not keeping with the changing social milieu or in direct conflict with changing times (e.g., demanding a bar on the use of mobile phones completely for a 15-year-old adolescent). This guideline outlines the special considerations that a clinician/counselor needs to make while doing psychotherapeutic interventions in children and adolescents. This guideline attempts to cover the important areas in this topic with focus on certain clinical conditions. However, this guideline is far from exhaustive and modifications may be necessary according to the clinical condition at hand. For purpose of this guideline, the term “child”/“children” will be used in references to children and adolescents. The term “child” and “adolescent” will be used for all children between 0 and 12 years of age and between 13 and 18 years of age, respectively.[2] DATA SEARCH METHODOLOGY The data search strategies for this clinical practice guideline included electronic databases as well as hand-search of relevant books, publications, or cross-references. The electronic search included PubMed and other search engines (e.g., Google Scholar and PsycINFO). Cross-searches of electronic and hand-search key references often yielded other relevant materials. The search terms used, in various combinations, were behavior therapy, psychotherapy, counseling, children, adolescents, etc. ESTABLISHING THE CONTEXT While working as a professional with families, one needs to listen carefully and take different perspectives into consideration. The professional needs to be able to appreciate and see the world from a child or adolescent's eyes as well as from those of their parents. Childhood and adolescence are times of first encounters and intense experiences in the present. They are periods full of joy and sadness, excitement, and fear, as well as rapid growth and new learning. To engage children and adolescents as professionals, we need to take time to appreciate their experience and to understand the world they move in while recognizing their relationships with their families.[3] When we engage with children, we also engage with their parents and the other significant members of their families. To be effective, we need to be sensitive to and appreciate the experience of being a parent in its ups and downs and its joys and sorrows. The lives of children and parents are so inextricably linked that we can hardly help one without helping the other.[3] Parents who bring their children to therapy also bring their own needs, concerns, and wishes. If we help parents with their own concerns, then we also help their children, and if we help children to change positively, then we also help their parents who care for them. Working effectively with families also involves appreciating and understanding the professional context from which we operate. As professionals we bring our own perspective, and that of our profession, to the therapeutic process. This includes our personal style and beliefs as workers, the theoretical models we subscribe to, the standing and context of the agency we work for, and the values and goals of our profession as a whole.[3] From a collaborative perspective, it is best to follow clients’ preferences in deciding what way to intervene to help them. Of course, this is not without limits as professional responses to client(s) goals are largely determined by the function and context of the professional agency. For example, it would be advisable to run therapeutic groups with children in a school set-up, where they would be an attentive audience, compared to parents. The opposite is true for an adolescent mental health setting, where parents would be keen listeners, while the adolescents would prefer to stay away. There are many different therapeutic models and ways to provide therapeutic services [Box 1], all of which have validity.[3] For example, behavior problems can be improved by either working with the parents, or with the children, or with both as a family unit.Box 1: Possible therapeutic interventionsESTABLISHING THERAPEUTIC ALLIANCE Counseling or working with children and adolescents therapeutically is a very different process than counseling adults. Children inhabit a different world than that of the adult and are at a different developmental level. They do not share the adult preference for language and verbal communication and the rules of adult conversation just do not apply to how children relate. Children like to communicate through play and creative activities [Box 2] as well as through conversation. Even adolescents who may appear to be more able to engage in adult conversation are at a transitional stage in their lives and share many of the preferences of younger children for structured activities and indirect and imaginative forms of communication.[3]Box 2: Creative therapeutic activitiesEstablishing a rapport with children is extremely essential, and it should not be sacrificed for practicing purely paternalistic way of medicine. Clinician should respect child's autonomy, while at the same time, he/she should not compromise with what is best for the child. The best form of practice is shared decision-making, with selective paternalism where needed, while working with children and families.[4] While establishing rapport, clinician must not assume that communicating with parents is enough and that whatever intervention he/she applies is routed through the parents. Clinicians’ and therapists’ interaction with the child may have a bearing on intervention outcomes. Even though the child is reluctant about the need for a consultation, he/she is usually aware of the events and/or discussions that happen around him/her. Therefore, a face-to-face conversation with the child, with the acknowledgment of child's understanding of his/her problem, is fruitful in the long run.[2] Play therapists are experts in using creative media to engage children in therapeutic conversation.[3] Ideally, they work within a designated play therapy room that has access to sand and water play, painting and artwork, dress-up materials, dolls, puppets, and construction play materials. While as a professional working in a different context (such as a child protection worker or a family therapist) you may not have access to a designated room or such an elaborate range of materials, it is still important to have access to some creative activities to complement verbal conversation fully to engage children and adolescents. Challenges in establishing rapport Clinician may face a huge hurdle in establishing rapport with the child when the remains mute during consultation. There can be several reasons for it. The clinician should examine various possibilities and manage them as they come. This usually warrants some extra time and labor on part of the clinician.[2] Table 1 enumerates the conditions that pose a challenge in establishing rapport and how to overcome the same.Table 1: Challenges in establishing rapportTREATMENT SETTINGS Psychotherapy for children and adolescents can be done in outpatient department, in inpatient setting, and/or in a consultation-liaison set-up. Whether done in an inpatient setting or outpatient department, the clinical setting should provide for adequate engagement of the child for the requisite length of time. The following factors need to be considered: Meeting a doctor can be intimidating for the children. Long waiting period can make them uncooperative and irritable during the interview Child clinics should have an attractive appearance, and toys, books, coloring pencils, and gaming zone should be made available. Walls painted in bright colors, with fables and cartoon characters, help in drawing attention of the child, and the child would be more happy to come back to the place, in case subsequent consultations are required The clinic can have few large blackboards with colored chalks to engage the child. Toys, papers, coloring pencils, Rubik cubes, and puzzle games should be there in the consultation room Drawing and play activities can help establishing rapport with the child and can be used as assessment tools, particularly with preschool children who may not be able to express their distressing experience verbally. All staff members in such clinics need to be trained in handling child and should be able to engage in activities with them.[2] When done in a consultation liaison setting: The therapist should be sensitive to the severity of the physical illness the child/adolescent is suffering from Ideally, one of the parents or a caregiver should be present to make the child comfortable His/her privacy should be respected; if possible, he/she should be taken to a separate interview room for initial assessment Too long interviews are discouraged, and therapist may have to depend on the caregivers as the primary source of information. Frequent visit to the child or adolescent may be required Therapy should be limited to crisis intervention during the length of hospital stay, and once the child or adolescent is stabilized/discharged, he/she can be taken up for psychotherapy in an outpatient setting or he/she can be transferred to a psychiatry inpatient set-up and psychotherapeutic intervention can continue there. ENGAGING PARENTS AS AGENTS OF BEHAVIOUR CHANGE The decision to bring a child for psychological help is generally taken within the family. The cultural values of each household might also decide what type of childhood difficulties is regarded as serious which warrants intervention. These values may additionally decide whether intervention is specially welcomed, resented, or feared. Because the family context is crucial in deciding a child's mindset toward psychological help, most of the child psychotherapists would like to meet the total family together as part of the preliminary assessment. Family meetings not solely provide a useful chance to discuss the total family's mindset toward referral but are also commonly an extra reliable way of mastering about family relationships than something the mother and father or youngsters can individually report. In working with parents, the therapist offers a structure of how to respond to emotional misery which has some core elements: The first and foremost is to establish a dependable setting in which it is viable to discuss very upsetting things. As with a child's treatment, sessions for mother and father have regularity in time and space, and this helps to contain the childish elements which are aroused The second thing is the creation with the dad or mom of some shared language to describe painful emotional states. Finding phrases for despair/sorrow/anguish is a help in itself because it offers the comfort of feeling understood. Many lonely or emotionally-disadvantaged mother and father may discover the resources for understanding their kids through the journey of feeling understood and perception their personal kids through the trip of feeling understood Third is the valuing of boundaries and differentiation: differences between parents and children and between experiences on her/his behalf. Perhaps, this might be likened to the ordinary behavior of a crying infant; however, when the baby gets no response, the screams stay lodged in the baby's head in an unbearable way Fourth, parents may be a very useful agent in implementing certain therapeutic principles for the child or adolescent behavioral problem at home setting, e.g., time out, positive reinforcement, negative reinforcement, time management, activity scheduling, conducting exposure and response prevention sessions, and helping the child to complete home assignments given the therapist Fifth, some mother and father are more responsive to group therapy. The group provides the alleviation that others, too, share a sense of failure, whether it be losing one's temper, failing to drop the child to school on time or to make him/her sleep at the desired time at night, or bearing with child's failure at school, quarrelsomeness with siblings or delinquent behavior. Group work looks to be helpful when there is an experience of social isolation, robust feelings of failure, and an absence of supportive partners. CLINICAL ASSESSMENT BEFORE THE PSYCHOTHERAPEUTIC ENGAGEMENT The goal of clinical assessment is to have a case formulation that would help in deciding the management.[8] Signs and symptoms as narrated by the child and caregivers or elicited by the clinician help in ascertaining the key areas that need to be addressed and also confirm or refute the presence/absence of a mental disorder. While doing an assessment, it is vital for the clinician to see the child in a psychosocial background, considering all the possible factors that could have played a role in precipitating and maintaining the particular disorder/behavioral problem, and to gather every detail regarding the illness so far, including the treatment history. Therapeutic alliance is very crucial in this context. If the child and his/her caregivers perceive a mutually beneficial relationship, the elicitation of facts becomes quite easy and so as the treatment which is then shared by the family also.[2] A good clinical assessment also provides a window of opportunity for the family/caregivers to reflect upon their own difficulties and working through it. Assessment also helps in deciding the nature of psychotherapy that has to be planned – whether it will be a short-term/long-term psychotherapy; crisis intervention/supportive kind of psychotherapy, or more extensive behavior therapy, or more rigorous psychodynamic psychotherapy to solve deep-rooted psychological conflict. Table 2 lists certain items which the clinician/psychologist should consider while planning psychotherapeutic interventions in children and adolescents.Table 2: Points to consider in clinical assessment from psychotherapeutic point of viewASSESSMENT FOR SUITABILITY FOR PSYCHOTHERAPY Not every child can be taken up for psychotherapy. Before we consider a psychotherapeutic intervention for a child or adolescent, multiple factors need to be considered – nature of diagnosis, availability of alternative mode of treatment (particularly medicines) and how effective are they, client choice, motivation for engagement, availability of time both on the part of the parents and the therapist, ability to pay for the sessions, expertise of the therapist in that particular type of psychotherapeutic intervention, and intelligence level of the child/adolescent. Supportive psychotherapy may be suitable for all age groups, whereas a more elaborative kind of psychotherapy, e.g., CBT or psychodynamic psychotherapy is suitable for older children or adolescents. Table 3 shows the factors to be considered for suitability for psychotherapy in children and adolescent.Table 3: Factors to be considered in evaluation for psychotherapyAnnexure 1 shows the template of a psychotherapy intake form for children and adolescents. Once the suitability for psychotherapy has been assessed, the sessions can start. Box 3 shows the do's and don’ts of psychotherapy with children and adolescents.[9]Box 3: Do’s and Don’ts of psychotherapyInitial psychotherapy sessions with children and adolescents can be very challenging due to the need to balance assessment, relationship building, caretaker/parent management, and case formulation with a client population that sometimes has little motivation for psychotherapy. STRUCTURING PSYCHOTHERAPEUTIC SESSIONS Shea proposed five stages of psychotherapeutic sessions: (a) the introduction, (b) the opening, (c) the body, (d) the closing, and (e) termination.[10] Introduction and opening There is something unique regarding the first contact between the child and the therapist. Because of formative issues and either negative desires or prompt negative transference responses, beginning associations can be expressly protective and antagonistic. It is not uncommon for juvenile customers to come up in the session and saying things such as “I’m not conversing with you and you can’t make me!” In such cases, setting up remedial collusion (portrayed prior) previously might be very useful. Another underlying contact procedure or system is to give constructive consideration and show enthusiasm for the customer's novel individual characteristics. This could incorporate giving a genuine commendation on the customer's dress or communicating an enthusiasm for something the customer brought to treatment. Secrecy is regularly an essential issue of worry for young people and ought to be talked about straightforwardly and legitimately. Psychotherapists ought to likewise impart referral data to customers. Children may ask why they have been referred and may assume that the referral clinician has provided inaccurate clinical data regarding him/her to the psychotherapist.[10] When working with grown-ups, specialists frequently ask things such as “What brings you for consultation” or “How could I help you.” These openings are inappropriate for psychotherapy with kids and young people since they expect the nearness of knowledge, inspiration, and a craving for help – which could conceivably be right. Opening sentences that put importance on collaboration, emphasizing disclosure, and beginning a process of in-depth exploration of client goals are more appropriate in such scenario. For instance, “I’d prefer to begin by revealing to you how I like to function with kids and young people. I’m keen on helping you be fruitful. That is my objective, to assist you with being effective in here or out on the planet. I will likely assist you with achieving your objectives. Be that as it may, there's a farthest point on that. My objectives are your objectives just as long as your objectives are lawful and solid.” Body When working with children, the essential errands related with the body or center phase of the underlying meeting for the most part include evaluation, job acceptance (i.e., clarifying the diagnosis and treatment approaches in detail), and possibly beginning of a psychological intervention.[10] Executing formal evaluation systems (e.g., Minnesota Multiphasic Personality Inventory and Rorschach) can be tricky with youths since they may not be fully aware of the requirement of such procedure or may be unduly suspicious of the motive of such procedure. Along these lines, psychotherapists ought to clarify and outline the reason and procedure of assessment.[11] Given the potential for youths to utilize carrying on safeguard components, holding on to manage tests until a sufficient helpful relationship has been set up is probably going to yield progressively substantial evaluation information. Meanwhile, less conventional appraisal strategies, for example, the wishes and goals and family constellation procedures, can be utilized to establish the therapeutic relationship and gather evaluation information. Clinically, it would be prudent that psychotherapists ought not to depend exclusively on verbal conversations while treating children. Clinicians can intentionally choose games, toys, expressive art supplies, and different objects of attraction for their clinic. Children may not be comfortable to use talking as a mode of self-improvement. Children can be encouraged to talk more freely by simple activities, e.g., modeling a piece of clay. The central matter of the story is that we ought not expect that children should discuss individual issues with an obscure adult from the beginning of therapy.[12] It is a rule rather than exception that psychotherapists will be able to execute formal therapy during initial few sessions with children. Be that as it may, like the utilization of preliminary translations in psychoanalytic psychotherapy, it is feasible for psychotherapists to utilize a mellow understanding or relational input and afterward check the customer's reaction. Closing and termination Time management is the central topic of closing and termination. The end starts when 5–10 min is still left in the session and is the point at which the psychotherapist stops collating new information as well as does not actualize any new interventions. Closing is the ideal opportunity for consolidation and transition, yet in addition it incorporates a few meeting tasks.[12] Psychotherapists should provide children with reassurance and support toward the end of the session. This can be as straightforward as, “I appreciated you for talking to me today” or “My gather that you intended not to meet me today, however you made it since we’re just about completed with our session.” Psychotherapists should provide positive feedback toward the end minutes. This feedback should be spontaneous and should include references of customer conduct during the session. Models include “When you discussed your fellowships, I could truly perceive the amount you esteem dependability” and “You have an incredible comical inclination.” Contingent upon the individual customer and the psychotherapist's hypothetical direction, it can likewise be valuable to request that the customer think about the session and remark or outline their feeling on the session's features. It is standard for the therapist to focus upon the future toward the end of the session. As this procedure unfurls, two essential issues are probably going to develop: (a) the following session and (b) potential homework. The next session The subsequent session(s) with children ought to be framed in a positive manner. Small remarks, for example, “I would like to see you one week from now” or “I am glad to work with you,” can add to setting uplifting desires. When working with young people, exceptional procedures might be utilized to fortify the treatment relationship and improve compliance. In particular, standard procedure of interpersonal psychotherapy for depression with adolescents (IPT-A) includes psychotherapists reaching the customer/parent over phone in between the first and second sessions. Potential homework CBT approaches should be included in homework for the client at the very outset.[13] However, it is essential to remember that for young people, schoolwork assignments should be moderately basic, functional, and doable; otherwise, it might evoke resistance. At times, it very well may be useful to abstain from utilizing the word “schoolwork” or “homework” with children, particularly if they recently had negative school and schoolwork encounters. Alternatives terms such as “task,” “assignment,” or “project” can be used. A BRIEF OVERVIEW OF DIFFERENT PSYCHOTHERAPEUTIC PROCEDURES IN CHILDREN AND ADOLESCENTS Cognitive behavioral therapy CBT involves that therapist and patient work as a team to examine and understand thoughts, feelings, and behaviors. Children may not be able to report their own feelings, thoughts, and behaviors. Moreover, thoughts, feelings, and behaviors of parents and other family members may have a bearing on the child. Therefore, the following areas should be explored before starting CBT with children and families. Developmental perspective Therapist must adopt a developmental standpoint while working with youngsters and adolescents, which is critical for planning the intervention. Therapist should consider the child's stage of autonomy and independence. This means giving older adolescents enough autonomy and working through with their treatment goals and for younger adolescents making certain that they have ample help from parents and concerned caregivers. Position of caregivers and other individuals in the kid's existence should be described at the start of the therapy Role of persons and different family or systems variables must be analyzed in retaining the kid's difficulties Families, schools, and other structures may also play a pivotal role in maintaining child's symptoms by adapting to it accordingly In addition to individual session with the child, sessions focusing on parent, teacher, and other concerned adults at regular intervals are also vital Treatment in familiar and natural environment often produces faster and long-lasting benefit structured treatment sessions. Treatment ideas should be tailored to children's developmental stage for the use of CBT with teens and adolescents. For example, because of lack of abstract thinking abilities in children, efforts to address cognitive biases, and distortions underlying anxiety, depression may be met with resistance. Various techniques have been proposed to concretize goal cognitions and abstract concepts. Symptoms can be symbolized as persona that the infant can relate to who must be vanquished Obsessions in obsessive–compulsive disorder (OCD) can be blamed on an external agent, e.g., a pesky bug, whose ideas must be fought Children can also be encouraged to play the role of detective or team up with a detective in verifying assumptions and beliefs. These developmental adaptations assist children in understanding ideas that are otherwise verbally explained, which may not be a suitable treatment vehicle for them. Cognitive behavioral play therapy With very younger kids, cognitive behavioral play therapy (CBPT) might also be indicated as it includes cognitive behavioral strategies into play-based interactions. Youngsters may have difficulty in appreciating principles of CBT; CBPT provides the opportunity for teaching and therapeutic work to happen during play. Many CBT ideas are modeled with puppets or different toys, e.g. demonstrating the child that a puppet gets over its worries the more it faces the challenges in environment. CBPT additionally borrows some principals from adult CBT, such as activity scheduling for a nonengaging child. Other developmental considerations include the child's age, verbal felicity, cognitive flexibility, and duration, intensity, and frequency of the symptoms. Younger adolescents are benefitted more from behavioral techniques than cognitive ones, mainly because they are often unable to report cognitions that accompany symptoms and behaviors Teenagers can benefit from cognitive strategies, e.g., relaxation exercises, imagery, and autosuggestions. Children over the age of 9 might have improved capacity for reporting and understanding cognitions and might gain from cognitive components of therapy Each child needs to be personally evaluated; however, competency in language skills may make the application of cognitive strategies difficult for older children as well. Family-related factors Kid's target symptoms should be seen within the family context for treatment planning in CBT. It is possible that significant others in the kid's life are accommodating the maladaptive behavior rather than discouraging it. For example, in OCD, household may additionally tolerate complex rituals that intervene with day-to-day routine activities to avoid the temper tantrum of the child when the rituals would be forced to stop. Parent/family involvement in therapy It is vital to have information about the family, and how parents think, behave, or emote, to understand the child's symptoms in a better way within a cognitive behavioral framework. Changes in household routines, dynamics, and di