Psykologarbete bland barn och unga

Question 1

KEY POINTS FROM PART 1: KNOWLEDGE OF CHILDREN AND THEIR CONTEXT

Answer 1

1. The process of CBT with children and young people needs to be informed by core aspects of developmental psychology.
2. The CBT therapist needs to consider the pattern of parent-child communication about emotional distress and how this applies for the referred problem.
3. Family and school factors should also be carefully considered in all aspects of the CBT work.
4. Parents usually have a key role in supporting CBT with children, both l theoretically and practically in the process of emotional repair. This may be less marked with respect to adolescents.
5. The care of children has a central place in all cultures and the meaning of childhood difficulties needs to be understood in terms of the culture of the child and family.
6. Children often express distress indirectly and through their behaviour rather than by describing it verbally.
7. Children may be reluctant to communicate about complex feelings and distressing situations or relationships but active and sensitive enquiry by adults i can enable children to communicate about complex feelings and problems.
8. CBT with children should not be assumed to be an individual therapy but one that needs to involve others in a significant way.
9. Children’s ways of thinking are different and less developed than for adolescents and adults but scaffolded interactions with an attentive adult may enable a child to fully engage and benefit from CBT work.
10. The developmental and cognitive capacities of adolescents indicate that many aspects of adult CBT techniques can be appropriately used with them.
11. The developmental challenges of adolescence, which include the need for increasing independence, developing a social identity and building and extending peer relationships, need to be taken into account in CBT work with this group.

Question 2

KEY POINTS FROM ASSESSMENT AND FORMULATION

Answer 2

1. CBT with children should begin with an assessment process in order to be clear about the nature of the problem. This assessment process should be sufficient to the task of establishing intervention goals and developing an intervention plan. This is described as a basic assessment. More complex problems are likely to need more detailed, extended assessments.
2. Formulation depends on the process of assessment. A basic formulation primarily focuses on maintaining factors which are sustaining the problem. More intractable and long-standing difficulties will require a developmental formulation which includes both maintaining factors and a developmental history of the difficulty.
3. Formulations are hypothesised explanations for a particular problem. CBT practice should always be guided by the current formulation of the case.

Question 3

KEY POINTS FROM EVALUATING PRACTICE

Answer 3

1. The evaluation of outcomes for individual case work is a key component of CBT with children and parents. This practice is important because the evidence base suggests that CBT will not be effective for some cases and i practitioners need to identify when progress is not being made as early as Possible.
2. Evaluation of outcomes is also important for the practitioner as it helps to identify those areas of the problem that are improving and those that are not. This feedback may improve the focus of therapy.
3. Evaluation should include multiple sources of information using goal-based measures, standardised measures and evaluation by participanis, particularly parents and teachers.
4. Systematic feedback of outcome to children and young people is an importtant part of evaluation and the therapist should ensure that all questionnaires and other evaluation methods are fed back to the client as routine.

Question 4

KEY POINTS FROM SETTING THE RIGHT CONTEXT

Answer 4

1. Children are vulnerable clients and it is essential that all therapy is conducted in a way that is respectful of their needs and has an explicitly ethical stance. Children’s wishes with respect to therapy need to be considered with care and should be a major but not overriding consideration in relation to the intervention that is offered.
2. The majority of psychological help for children is provided by parents. Wherever possible, CBT should support the existing role of parents to provide psychological help for their offspring and should not (inadvertently) become a barrier for this. The preferred position is for all CBT with children to have a high level of involvement of parents and carers.
3. CBT with children may involve the parents in a number of different ways | including as ‘co-therapists’. The challenge for the CBT practitioner is to be explicit about the role that the parent is going to play in therapy and to be flexible to this role changing as therapy progresses.
4. CBT often includes an aspect of learning. School stoff have expertise in learning and pastoral care and therefore collaborative practice with schools is a major aspect of effective CBT work with children, in contrast to CBT with adults.

Question 5

KEY LEARNING POINTS FROM THE THERAPEUTIC ALLIANCE

Answer 5

1. Demonstrating empathy is a key aspect of CBT work with children and parents. The literature around mentalisation provides a useful elaboration of the theory and practice of trying to understand the mind states of others. In our view, the use of aspects of mentalisation provides a very significant J enrichment of CBT practice.
2. Mentalisation makes it easy to be explicit that part of the therapisfs job is to try to understand things and that this will need everyone to help with this.
3. CBT needs to adapt to the expectations and interests of children and be child-centred, which means being respectful of the views of children, being aware that they see things differently from adults and acknowledging that they have often not had much of a choice about coming for help.
4. CBT with children may involve conversation, role plays, drawing and even i direct practice with the child in the room. Such a range of ways of working needs to enable the child to adopt their own individuality within such | activities, and that this may result in creative approaches to tasks. The therapist needs to find a balance between establishing structure and i boundaries alongside building capacity for creativity and adaptation of activities.

Question 6

KEY POINTS FROM COLLABORATIVE PRACTICE

Answer 6

1. The key stance for CBT with children and parents is one of collaboration. Achieving authentic collaboration with both the child or young person and the parent is often a complex task, particularly where there is conflict and disagreement about the nature of the presenting problem.
2. Joint session planning and being goal focused both present the therapist with the task of integrating ideas and experiences of the child with the therapisfs own ideas and therapeutic plan. This is not just about going along with what the child and parent believe. The challenge is to find a way in which the therapists own knowledge and experience can have a place in the child’s understanding of his difficulties.
3. The degree to which the practitioner adopts an expert position in CBT with children is subtle. The knowledge and experience of addressing similar problems is consistent with the expectations of the clients who come to seek help. However, this ‘expertise’ is not helpful if it inhibits the child and the parent from thinking for themselves. What is desirable is for the therapist to provide some perspectives which facilitate thinking in the child rather than inhibit it.
4. The process of providing a rationale to the child as to why the therapist is suggesting certain things is fundamental not just because it models communication but because such transparency allows the child to adopt a position in relation to the rationale itself. It is easier for the child to disagree with an idea than to disagree with the therapist.
5. The CBT practitioner needs to pay particular attention to ensuring that the child is able to actively participate in the intervention and does not become passive within a process which is being done to the child. The techniques of summarising, feedback, and planning practice are all crucial to ensuring active involvement of the child in therapy.
6. Summarising is a method of ensuring that the therapist can check out whether the child understands things in similar ways to the therapist and parent. It also allows time for key points from conversations or activities to be reflected on and possibly challenged.
7. The therapist may need to actively encourage honest comment and the expression of negative feedback in an explicit way in order for this to not become a gesture rather than an active part of the intervention. Any suggestions from children should be referred to in the subsequent session.
8. Children are brought to therapy and may have very little internal motivation to change. The stages of change model supporting motivational interviewing is a very helpful framework for working with young people who are unclear about what they wish for from therapy.

Question 7

KEY POINTS FROM STRUCTURING THE THERAPEUTIC PROCESS

Answer 7

1. Preparing for the session is an opportunity for CBT practitioners to model a balance between preparing enough in advance so the session does not feel chaotic, whilst not sticking rigidly to these pre-prepared activities if they do not meet the needs of the child or young person.
2. It is important that the therapist facilitates the development of a joint session plan that contains an appropriate number of activities, and conducts the session at a pace appropriate to the needs of the child.
3. The child/young person and/or parent carrying out tasks between sessions is one of the core features of CBT. The therapist needs to ensure that adequate time is given to planning between-session tasks and hearing feedback on how these went. The key skill for the therapist is to modulate the demands of the task to the capacities of the child.

Question 8

KEY LEARNING POINTS FROM FACILITATING PSYCHOLOGICAL UNDERSTANDING

Answer 8

1. A key part of CBT with children and parents is working to develop their understanding of their own and each other’s thoughts and feelings, particularly in relation to the presenting problem.
2. Providing psycho-education about CBT is an important part of facilitating understanding. This includes giving the child/parent information about the theory and the way it understands particular psychological and emotional problems; as well as ensuring it makes sense and seeking feedback about the child/parenfs view about these ideas.
3. Developing some differentiation between thoughts, feelings and actions is a central technique in CBT and, for children, considerable care may be needed to gradually build the child’s capacity to recognise these different internal processes.
4. The capacity to differentiate feeling states often needs to be explored as children may well begin therapy with somewhat dichotomous (alright/not \ alright) ways of describing their emotional states. Emotional recognition provides a set of techniques for elaborating these descriptions.
5. The process of discovering cognitions is based on the understanding that children, like adults, are not always aware of the assumptions and beliefs that they bring to problem situations. For some children, these beliefs and assumptions may have a key maintaining role in the child’s difficulties and need to become more explicit.
6. Formulations are more useful when they are jointly constructed with the child and parent. Sometimes developing a shared perspective on a child’s difficulty is only partially achieved, but the preferred practice is to work to this objective as much as possible.

Question 9

KEY POINTS FROM FACILITATING ACCEPTANCE AND COPING

Answer 9

1. CBT with children is a method of understanding a child’s difficulties in order to facilitate changes in the nature of the problem or to increase adaptability to it. Reducing the negative impact of a problem may be enhanced by acceptance of things which are not amenable to change and improved coping with such factors.
2. The application of ‘acceptance’ approaches for child work is less developed than with adults but is a promising addition to the range of options available o the CBT practitioner.
3. Relaxation is both a set of specific techniques for reducing uncomfortable states of arousal and tension and also a general principle which is well recognised as a component of emotional well-being. Encouraging relaxation may involve building on existing methods and experiences of children and their parents as much as offering completely new methods of supporting this aspect of the intervention.
4. Problem-solving is often a key component of CBT with children. This apparently simple technique is useful for children and parents partly because the presenting problem often impacts on their capacity to think things through in a logical way. The use of problem-solving methods often involves sensetive negotiation between the parent and child as to the decisions or actions that arise from such a process.

Question 10

KEY LEARNING POINTS FROM FACILITATING CHANGE: BEHAVIOURAL TECHNIQUES

Answer 10

1. Behavioural techniques often have a very important role in the CBT intervention both in changing a young person’s behaviour but also in providing a way of exploring feelings and cognitions.
2. Behavioural methods need to be based on core behavioural principles which suggest that positive approval, attention and responses from significant others is likely to encourage a child to behave in ways that elicit such i responses.This core principle underpins the idea of contingency management and is central to many aspects of parenting.
3. Behavioural activation and exposure both have a very important role in CBT for depression and anxiety respectively. The current evidence would suggest that effective practice involves a combination of behavioural and cognitive techniques for these problems.

Question 11

KEY LEARNING POINTS FROM FACILITATING CHANGE: COGNITIVE TECHNIQUES

Answer 11

1. The overall approach to changing cognitions in a young person and/or parent needs to be tentative and exploratory. The therapist needs to remain aware that the only person who can change anyone’s cognitions is the person herself.
2. Replacing negative situational cognitions with more adaptive coping self statements can be helpful for some children and parents. This technique called positive self talk particularly focuses on coping in situations which evoke raised affect in the child or parent.
3. Cognitive change techniques often try to address the non-adaptive ways of thinking identified in Chapter 10, such as dichotomous thinking or catastrophising, and promote balanced thinking. The emphasis here is for the therapist to understand how the child or parent has come to have such ideas and feelings and then to explore alternatives. It is crucial not to consider alternatives too early in this process.
4. A range of techniques have been presented for exploring thinking. These techniques should be adapted to the therapisfs own style of working and practice.

Question 12

Richard F Catalano, Abigail A Fagan, Loretta E Gavin, Mark T Greenberg, Charles E Irwin Jr, David A Ross, Daniel T L Shek. (2012). Worldwide application of prevention science in adolescent health. Lancet 2012; 379: 1653–64.

Key messages

Answer 12

• Behaviour problems are important causes of adolescent morbidity and mortality
• There is sufficient evidence from controlled trials that carefully designed preventive
interventions can improve adolescent health
• Effective adolescent health programmes should include a combination of preventive
policies and programmes before and during the second decade of life
• A programme of public education is needed to ensure that policy makers,
practitioners, scientists, and the general public are made aware of the health and
social benefits and cost savings from evidence-based preventive interventions
• Research is needed on how to most effectively take such evidence-based prevention
interventions to scale, including research on how to build community capacity, identify local need, match need to efficacious prevention interventions, support and sustain these interventions, and learn what adaptations might be needed for programmes designed in high-income countries to be effective in low-income and middle-income countres
• An international agency such as WHO, UNICEF, or The World Bank should be encouraged to convene a guideline development group to identify broad behavioural health risks confronting adolescents, recommend preventive policies and programmes that have evidence of reducing these risks and promoting adolescent health, and advise on actions that countries should institute to take up and sustain a national programme to promote adolescent health
Databases should be developed, including a database of community surveys that comprehensively measure structural and intermediate determinants and health and behaviour problems, and a database of efficacious preventive policies and programmes across behaviour problems and health outcomes, the structural and intermediate determinants they address, and their target populations