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 Therefore, a conversation with the child, with the of child's understanding of problem, is in the are in creative to engage children in therapeutic they work a play therapy that to and and and play materials. 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