By- Dr. Sunil Suthar

Psychosocial approaches and psychotherapies as

relevant to Child Psychiatry

Under Guidance of Dr. Yogesh Satija

Content

Introduction

Difference from adult psychotherapy

Psycho- education

Parent counseling

Psychodynamic Psychotherapy

cognitive-behavioral Therapy

Family Therapy

Group Psychotherapy

Play Therapy

Other Therapies

Indications

Introduction Psychotherapy is a very general term that implies treatment of mental

dysfunction by psychological (medicine) rather than physical methods.

Dynamic psychotherapy based on the theories of Sigmund Freud and his daughter Anna Freud, Melanie Klein, and others has been the mainstay of individual child therapy.

More recently, Virginia Axline adapted the ideas that Carl Rogers applied to counselling and developed ‘play therapy' as a specific technique for children.

Subsequently, brief psychotherapy and interpersonal therapy have grown out of the need to update psychodynamic methods.

Various forms of cognitive therapy are now increasingly used for children, although they were developed for the treatment of adults. These therapies focus on a problem-solving approach to resolve current issues, rather than on resolving unconscious conflicts based in the past.

The ability to distinguish fact from fantasy is an important prerequisite for psychotherapy.

If the therapist ignores developmental issues it is likely that treatment will be harmful rather than helpful.

The aim is to improve function by changing cognition and emotions through the therapeutic relationship, by means of language, play, art, or drama.

• Psychotherapy with children requires a high level of skill.

• Psychotherapy is directed more at psychopathology than normal reactions to stress. It is therefore essential to know about the normal range of children's responses to life events. For example, a 5-year-old child whose mother has just died will grieve differently from a 10-year-old child, because at 5 years of age most children have not yet developed a clear concept of death. Grief in a 5-year-old is most strongly influenced by the way the adults around the child react to the death, whereas a grieving 10-year-old child, although responsive to guidance from the adults around, will also have his or her own unique way of coping with grief. As a general rule, the younger the child the more important it is to consider the attitude and mental state of the parents.

Differences from adult psychotherapy

Basic principles involved are quite similar to those involved in the treatment of adults.

The most notable difference between children and adults is the difference in the rate of developmental change. (immaturity and lack of life experience that children have.) This makes children highly dependent on adults for emotional and physical security.

Consent from the child and both parents.

Children cannot be expected to find their own solutions without guidance and support.

Another major difference is that children do not come to treatment at their request. They are brought by their parents. The reasons for treatment must be explored and explained in a way that is understandable and meaningful to the child. As a consequence, one of a therapist's first tasks is to stimulate a child's motivation for treatment.

The child psychotherapist must recognize the critical and central role of the parents or caretakers in the child's life.

Play is the central medium for communicating with younger children.

Transference in children and adolescents is more complex than with adults.

Working with parents is essential in psychotherapy with children and adolescents.

Psycho-EducationGoals of Psychoeducation- Teach parents and children about

• The child’s illness & its treatment

Provide support• Peers (“I’m not the only one”)• Professionals - understand the disorder

Adherence for pharmacotherapy

It is helpful in reduction of caregiver stress (Worry about the future, Stigma, Guilt and blame )

PARENTS COUNSELLING Following points are noteworthy in this contest (Madhavan,1990). 1) The child's actual condition should be explained in simple words to the parents.

2) Enough time must be taken while counseling.

3) Misleading, giving false information or building false hopes in parents must be avoided.

4) Information regarding professional help for treating associated conditions like seizures, hyperactivity, psychosis etc. must be made available to the parents.

5) Attitude such over protection ie., doing everything for the child and shielding them from any challenging situation, should be corrected as it hinders the development of whatever capacities the child may have.

PARENTS COUNSELLING 6) The attitude of rejection, that is ignoring the child thinking that he is good for nothing

should be changed so that the child can be helped to learn by systematic training.

7) The parents should be made aware of what they may expect of their child

8) Some patents suffer from guilt feeling assuming that they are responsible for their child's condition. It should be explained that the condition is due to causes over which parents have no direct control.

9) The counselor should explain the effectiveness and role of the parents and other family members in training a mentally retarded.

10) Some parents believe that training a mentally retarded child needs specialized skills and they may not be able to train their child. Parents should be explained that training a mentally retarded child dose not need complex skills and repeated training in simple steps, they can be taught.

11) Parents should be helped to learn the skills in training through demonstrations and observations.

Individual Psychodynamic Psychotherapy

A. Freud first articulated the aims of child psychoanalysis as a return to the path of normal development.

Subsequent analysts have emphasized the aims of increased mentalization, self-understanding, self-regulation, personality integration, self-expressiveness, self-esteem, flexibility, increased frustration tolerance, and capacity to play.

The indications for psychodynamic psychotherapy generally include children with internalizing disorders.

Psychodynamic psychotherapy focus on intrapsychic conflict.

It focuses on improving children adaptive skills and diminishing specific symptomatology.

Cognitive–Behavioral Psychotherapy for Children and Adolescents

It emphasizes how children may use thinking processes and cognitive modalities to reframe, restructure, and solve problems.

generating alternative ways of dealing with problematic situations.

multiple studies are found to be effective in the treatment of child and adolescent mood disorders, OCD, and anxiety disorders.

Family-focused CBT has also been used in the treatment of pediatric bipolar disorder with promising success.

Using a variety of components, including behavioral exposure, cognitive restructuring, and psycho-education, CBT has been shown to be adaptable to a variety of formats, including individual, family, and group treatment.

Cognitive therapy

The only modification that is required for their use in children is to adapt them to the developmental stage and the level of cognitive ability that the child has reached.

Cognitive therapy has a theoretical advantage for use in children in that its focus is more on the present and the future, in contrast to most psychoanalytically based psychotherapy.

Its approach is strongly based on learning new ways of coping.

Cognitive therapy is pragmatic and active rather than passive and reflective.

Basics Principles of REBT

.

Albert Ellis

Core Irrational Beliefs For Children

• It’s Awful If Others Don’t Like Me. • I’m Bad If I Make a Mistake.• Everything Should Go My Way; I Should Always Get What I Want.• Things Should Come Easily to Me. • The World Should Be Fair.

How Do You Introduce CBT to Children in An Engaging and Understanding Way

• Visuals - Thought Bubbles; Cartoons; Picture Book• Baseball Metaphor • Butterfly Thoughts Worksheet• Thought Flower Garden• Rational or Irrational? Game• Best Friend Technique• Reverse Role Playing• Empty Chair Technique• Erase the Irrational• Analyze TV Shows or Movies• Puppets• Rational Advice Column• Rational Emotive Imagery• “Meet Thoughts, Your Thought Maker” by R. Avery

Externalizing Problems Beliefs Associated With Externalizing Disorders (Anger)

B = Musts Instead of Preferences; Low

Frustration Tolerance; I Can’t Stand It!

Examples: I must have what I want! The world should be fair!

Other people must treat me the way I wanted them to, and when they don’t, they deserve to be punished!

Challenges for Anger Related Irrational

Beliefs

Where Is It Written That You Should Always Get

What You Want, That The World Must Be Fair, and That You Always Have To

Get Your Way?

Functional Disputes How Is Your Anger Helping You? Or, is it Like Pouring Salt On An Open Wound?

Behavior Therapy

Reinforcement / Contingency management - Parent praise (Verbal praise, Encouragement, Attention, Affection, Physical proximity)

Time out - is the removal of a child or adolescent from all reinforcement for a specified period of time after a targeted misbehavior.

Structured class room training (to learn new material & maintain the acquired learning, ''special schooling'').

Social Skills Training

• Sometimes used to teach the child skills needed in peer relationships and other settings

Interaction skills Conflict resolution Problem-solving skills Anger management

• Results of studies of this strategy are inconsistent

• More effective when taught in group settings such as summer camps, school-based, and after-school settings

Group Psychotherapy

A number of factors, described by Irving Yalom, may contribute to the effectiveness of groups.

Hope: Hope may be generated by gathering with others who are experiencing similar difficulties and by observing others actively mastering the problems.

Universality: Children and adolescents with psychiatric disorders often feel isolated and alienated from peers. Working together in groups may diffuse the isolation and help children and adolescents view their disorder as only a small part of their overall identity.

Group Psychotherapy

Imparting Information: Children and adolescents are familiar with a format of gaining new information in a group setting, such as in school. The group therapy format provides an opportunity to reinforce learning when the child or adolescent helps or demonstrates what he or she has learned to peers.

Altruism: Helping other peers in a group setting by supporting them and identifying with their struggles can improve a child or adolescent's self-esteem and help them gain a sense of mastery over their own issues.

Improved Social Skills: Group therapy is a safe format in which children and adolescents with poor social skills can improve their interpersonal and communication abilities under the supervision of a leader and with peers who also benefit from the practice scenarios.

Individual versus group therapy

There are no agreed guidelines to determine which child would benefit from an individual or from a group approach to psychotherapy.

Some children, however, find the emotional intensity of undivided adult attention too much to cope with and learn better from others in a group situation.

As the selection of cases for group psychotherapy tends to be determined by the therapist's skills, there is no clear evidence that one approach is better than any other.

Nevertheless, there is a growing literature on group therapy for children and an increasing interest in this method of treatment if only because the cost per case is likely to be less.

Family Therapy• There are many models of family therapy with different theoretical bases. • They have in common a focus on treating the family as the defined unit for

therapy: problems evolve from the family structure and history, and although the child or adolescent may be the ‘identified patient,’ the basic problems rest within the family.

• Varieties of Family Therapy-1. Strategic (Haley, Madanes) – conflicts and negative pattern of

interaction2. Structural (Minuchin) - dysfunctional patterns (ineffective closeness,

excessive distance)3. Systemic (Bowen, 'The Milan model') - explore the way the family

system has created rules, and hierarchy.4. Behavioral (Patterson) - identifies problematic behavior in children

and helps parents reinforces positive behavior.

Inpatient Psychiatric, Partial Hospital, and Residential Treatment for Children and Adolescents

• are appropriate settings for children and adolescents with mental disorders(with serious psychiatric disturbances ) who require a highly structured and supervised setting for a substantial time.

• Residential settings offer many treatments, including behavioral management, psychotherapy, medication, special education, and the therapeutic milieu itself.

• Partial hospitalization /Day treatment programs-alternative to hospitalization to provide short-term crisis stabilization. Family therapy, group and individual psychotherapy, psychopharmacology, behavioral management programs, and special education are integral parts of these programs.

• Children who are likely to benefit from day treatment may have a wide range of diagnoses, including autistic disorder, conduct disorder, ADHD, and mental retardation.

• Education Process in Residential Treatment

Case• A 7-year-old boy was brought for treatment by his working-class parents,

who were concerned about his depressive irritability and argumentativeness, which had created great tension in the family. When seen individually, the therapist asked the child about his understanding of why they were meeting. The boy responded, “I don't know.” The therapist then asked why he thought the parents had brought him, and he again avoided the question. Later in the interview the therapist returned to the issue while the child played out a puppet scene of different animals fighting. The therapist explored how the animals felt, and the child said “sad.” As the play developed, the therapist explored whether the child might also be sad. This seemed to resonate, and the child nodded his head “yes” and went back to playing with the puppets. As the session closed the therapist suggested that in meeting together they might come to understand “why you feel sad and what we can do to help you feel better. How does that sound to you?” The boy looked up shyly and nodded his approval.

Play therapy

is– Symbolic – The world of the child– Acts out real life conflicts and issues– Fun– Play therapy is just that -- it is not a talking therapy, but it can lead to

that.– a method of communicating in a therapeutic way with children

• Play therapy is generally employed with children aged 3 yrs to11 yrs and provides a way for them to express their experiences and feelings through a natural, self-guided, self-healing process.

• Play therapy can be divided into two basic types: 1) Nondirective play therapy (client-centered and unstructured play

therapy)– it is a method in which children are encouraged to work toward their own solutions to problems through play. It is typically classified as a psychodynamic therapy.

2) Directive play therapy – it is a method that includes more structure and guidance by the therapist as children work through emotional and behavioral difficulties through play. It often contains a behavioral component and the process includes more prompting by the therapist. Directive play therapy is more likely to be classified as a type of cognitive behavioral therapy.

Typical Goals of Play Therapy

• Enhance child’s self control, self-concept, and self-efficacy.

• Help child become aware of his or her feelings.

• Have a place where child can feel safe in exploration of self.

• Learn and practice self-control and alternative behaviors.

• Develop capacity to trust adults.

• Develop capacity to relate to an adult in an open, positive and caring manner.

Equipment

• Puppets• Art• Sand Play• Games• Doll Houses• Almost any toy• Paper and color pencil

• Cars and Trucks• Toy guns• Costumes, dress-up• Water play• Games, i.e, cards,

checkers, etc.

Toys Needed for Play Therapy Room

• Scary toys– Client’s can use these to deal with fears– Plastic monsters, snakes, bugs, bears, lions,

dinosaurs

• Nurturing Toys– Client’s can use these to play out family

relationships and events– Doll house, dolls, puppets, baby dolls, kitchen set

Source: InAPT conference 2005

Toys Needed for Play Therapy Room

• Aggressive Toys– Clients use these to express anger and aggression

and explore power and control issues– Guns, play knives, hammer and nails, toy soldiers,

punching bag

• Expressive Toys– Clients use these to explore relationships, express

feelings, deal with problem/solution– Crayons, paper, scissors, paint, craft items.

Source: InAPT conference 2005

Four different models of Play Therapy

Virginia Axlin, (1947) - Child-Centered Play Therapy

Clark Moustakes, (1973) - Relationship Playtherapy

Bernard G. Guerney, Jr. (1964) - Filial therapy

Family Play Therapy

Other Therapies

Speech/Language Therapy– Picture Exchange Communication System– Auditory Integration Therapy

Occupational Therapy– Sensory Integration

Psychotherapy Effectiveness

• Lack of well-controlled empirical studies makes it difficult to draw firm conclusions

• A large well-controlled study in the United Kingdom by Kolvin et al. found that group psychotherapy and behaviour modification produced greater improvement in school-aged children than parent–teacher consultation or no active treatment at all. Kolvin et al. concluded that psychotherapy is effective.

• More research is needed!

Indications• Psychotherapy usually is indicated for children with emotional disorders

that seem to be sufficiently permanent to impede maturational and developmental forces.

• The indications for psychodynamic psychotherapy generally include

children with internalizing disorders.

• Intellectual disability – Special education, Social intervention, behavioral therapy.

• Reading disorder , Mathematics disorder, Written expression disorder – Special teaching programmes, Individual education programme.

• Communication disorder (stuttering)- Speech therapy, Therapy to reduce anxiety and tension

• Autism- Education and behavioral intervention ( structured class room training) is currently treatment of choice.

• Asperger syndrome- Self sufficiency and problem solving technique to

improve social behavior and peer relationship.

• ADHD – Family therapy, group therapy to refine social skills and increase self esteem.

• ODD and Conduct disorder – Family therapy to teach parents how to alter their behavior, discourage child’s oppositional behavior and encourage appropriate behavior, social skill training, problem solving skills.

• PICA – Behavioral techniques ( Mild aversion therapy, negative reinforcement, positive reinforcement, modeling, shaping).

• Rumination Disorder – Behavioral techniques eg. Squirting lemon juice into infant’s mouth whenever rumination occurs.

• Enuresis – Behavior technique- toilet training, restricting fluid before bed, night lifting to toilet train the child, Bell and pad apparatus.

• Encopresis - Behavioral therapy (toilet-use skills)

• PTSD – Crisis intervention, Trauma focused CBT, Eye movement desensitization and reprocessing (EMDR).

• Separation anxiety disorder – CBT is first line treatment.( Cognitive strategies, relaxation exercise and graded exposure)

References• Kaplan and Sadock’s Comprehensive Text Book of Psychiatry 9th edition• Kaplan and Sadock synopsis• Oxford Text book of psychiatry• Kolvin, I., Garside, R.F., Nicol, A.R., MacMillan, A., Wolstenholme, F., and Leitch, I.M.

(1981). Help starts here. The maladjusted child in the ordinary school. Tavistock, London Kolvin, I., Macmillan, A.K., Nicol, A.R., et al. (1988). Psychotherapy is effective. Journal of

the Royal Society of Medicine, 81, 261–6.• Clinical Child Psychiatry, Second Edition. Edited by W.M. Klykylo and J.L. Kay© 2005 John

Wiley & Sons Ltd ISBN: 0-470-0220-94

• Autism Society of America −www.autism-society.org

Autism Speaks – 100 Day Kit −www.autismspeaks.org

Centers for Disease Control and Prevention −www.cdc.gov

American Academy of Pediatrics −www.aap.org

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