Session 7: Exploring some of the interventions to support children’s mental health

In the last session, you looked at some of the roles of different professionals and the processes that relate to facilitating children’s mental health and wellbeing within the child’s community. This session, you will be looking in more depth at several of the other therapeutic approaches that might be used by practitioners such as therapists and counsellors. You will also watch a video demonstrating how engaging playful activities are used with younger children and how these can be adapted as forms of therapeutic occupation or activities.

You will be introduced to the ways that specially trained dogs are used therapeutically in non-clinical settings and what the positive advantages of this creative approach might be. You will also have the opportunity to reflect on the use of medication to treat some mental health conditions, in particular attention deficit hyperactivity disorder (ADHD). In addition to this, you will explore behaviour management through the use of a particular toolkit and re-examine the role of schools, parents and wider organisations in helping to support children’s mental health and wellbeing.

Now listen to the audio introduction to this session.

Download this audio clip.Audio player: Audio 1

Show transcript|Hide transcript

Transcript: Audio 1

LIZ MIDDLETON

In last week's session, you looked at some of the roles of different professionals and the processes that relate to supporting children's mental health and wellbeing within the child's community. This week, you'll be looking in more depth at several of the counselling and therapeutic approaches that might be used by practitioners, such as therapists and counsellors.

You'll also watch video material demonstrating in more detail how playful activities are a very useful resource with younger children and how you can adapt them. You will also be introduced to the ways that specially trained dogs are employed in therapy for specific reasons, and what the expected outcomes in play therapy might be.

You will also have the opportunity to look at the use of medication for some mental health conditions, such as ADHD, explore behaviour management through the use of a particular toolkit, and re-examine the role of schools, parents, and wider organisations in helping to support children's mental health and wellbeing. You'll be asked to reflect on how supporting wellbeing is the responsibility of everyone within an organisation.

And lastly, you'll be asked to look at the ways that parents may be helped to manage children's behaviour and support their wellbeing. The final practice quiz is included. Have a good learning session.

End transcript: Audio 1

Download

Audio 1

By the end of this session, you will be able to:

• recognise how the power imbalances between child and adult can affect the therapeutic processes
• understand what is meant by cognitive behavioural therapy (CBT)
• appreciate the role of play and creativity in counselling and therapy with young children
• realise some of the challenges associated with prescribing medication to treat a child’s mental health condition
• understand how parents might be helped to manage children’s behaviour and support their wellbeing.

One of the issues to be aware of around counselling and all other talk-based therapy is how terms are used by a range of professionals across numerous different contexts. For example, teachers and support workers in schools and in the social care services may well use counselling micro skills very effectively (e.g. active listening and paraphrasing). However, they will not be trained counsellors or registered health professionals, which include specialists like clinical psychologists who have had extensive therapy training, often to doctoral level. In order to be an accredited counsellor or psychotherapist specialised in working with children, you need to have completed training approved by the British Association of Counsellors and Psychotherapists (BACP). Other therapists, for instance practitioner psychologists (which include clinical psychologists), occupational therapists, and art therapists (specifically music, dance and drama therapists) have completed accredited training to at least degree level and are registered by the Health and Care Professions Council.

When working with children in any therapeutic way, adults should be aware that children often come into therapy through referral by other agencies and carers, as you have seen in Session 6. They are therefore not necessarily entering into the relationship with a therapist through their own choice, but because adults feel they would benefit from the process.

Figure 1 Child with therapist

Show description|Hide description

This is a photograph of a child in a counselling session.

Figure 1 Child with therapist

Children are not emancipated adults and as such they will always be part of a system which includes carers (usually their parents and other family members) and professionals (especially teachers) who make decisions on their behalf, often without sufficient negotiation with the child themselves. This means that the child can struggle to understand what is going on, especially in the case of a referral to CAMHS where the child is unaware of the depth of concern the adults in their life have about them. For example, young children are not always perceived as being competent enough to make important decisions, even around their lived experiences, but being unaware of a CAMHS referral can mean that they struggle to engage in their initial assessment, because they may incorrectly assume they are being seen in CAMHS as part of a punishment. Furthermore, children are developing and, despite being extremely adaptable as well as capable in many respects, they are emotionally vulnerable, especially if they have had to deal with complex challenges in life such as trauma.

So, adult–child relationships within therapy can still mirror power imbalances and potential misuses of power (including abuse for some) that children may well have endured prior to entering therapy. For this reason, therapeutic work with children needs to be undertaken skilfully by suitably qualified personnel with appropriate safeguards in place to protect the child.

Cognitive behavioural therapy (CBT) is a widely used evidence-based form of treatment that is used with children and adolescents, and is delivered in a developmentally appropriate way to fit with individual children’s needs in terms of their cognitive, social and emotional skills.

CBT works on the basis that an individual’s thoughts, feelings and behaviours are all interrelated. For instance, a child might struggle to manage negative (or maladaptive) thoughts, such as ruminating about their parents dying in a volcanic eruption in the UK (where these eruptions are unheard of) which then results in the child feeling sad and anxious, to the point where they frequently become tearful. This in turn results in ‘extra clingy’ behaviour where the child can even become aggressive when their mother tries to leave them for fairly short periods of time. CBT, after a thorough psychosocial assessment, would then involve supporting the child to develop more positive (or adaptive) thoughts that challenge the ruminations as well as skills (such as controlled breathing) while working with the child’s parents to employ behavioural strategies to treat the child’s anxiety.

Figure 2 Cognitive behavioural therapy

Show description|Hide description

In the centre of this image are the letters ‘CBT’. Next to them are the labels ‘Thoughts’, ‘Feelings’ and ‘Behaviour’.

Figure 2 Cognitive behavioural therapy

The process usually involves a therapist working regularly with an individual child (perhaps weekly or fortnightly) often for an hour over a number of sessions. The main aim is to help modify or replace existing ‘faulty thinking’ and unhelpful behaviours, which in turn help to improve a child’s mood and improve their functioning, hence resolving or lessening the presenting problem. The focus in CBT is therefore centred on the present rather than working through an individual’s earlier life experiences (as might happen in other forms of psychotherapy).

The implementation of CBT in practice involves three key stages: assessment; intervention and evaluation (Zandt and Barrett, 2017).

The ABC model is often used at the initial assessment stage as a means to make sense of the presenting issues.

• A being the activating event (i.e. what seems to trigger the behaviours/responses)
• B being the individual’s belief system or attitude in relation to the event
• C being the consequences as reflected in behavioural or emotional reactions.

The key idea behind CBT is that when faced with any external event we can change our thoughts, feelings and behaviours, although this is not always easy to do, and that is why so many people have benefited from CBT as a form of therapy. As a result, we can challenge how we perceive events and look at alternative and potentially more helpful ways to view our experiences.

As part of intervention, steps D and E are included (as shown in Figure 3):

• D being the challenges/questions around the more negative, self-defeating belief
• E being the effect of challenging previous attitudes and beliefs.

Figure 3 The ABCDE model showing cognitive behavioural therapy in adults

Show description|Hide description

There are boxes for each of the letters ABCDE. In the boxes is the following text. A = Activating event or Adversity. B = Beliefs about Event or Adversity. C = The emotional Consequences. D = Disputations to challenge self defeating belief. E = Effect or consequence of challenging self defeating belief.

Figure 3 The ABCDE model showing cognitive behavioural therapy in adults

To help illustrate how CBT can be applied in practice, you will first be asked to think about a case study of an adult before thinking about psychotherapy with children. Any new ways of dealing with the problem that have been put into place and practised are evaluated to see how effective they have been. For example, this will include whether there have been changes in any interactions, how the person is now feeling and how they currently see themselves.

If we delve more deeply into our own negative thinking and the automatic responses and conclusions we can reach, we are more likely to find alternative ways to solve our problems. We can gently interrogate ourselves to see if our original thinking holds true.

CBT techniques can work in a similar way with older children and adolescents, using worksheets or other resources to help them to make sense of the problems they are encountering. They can talk and draw diagrams to help explain what is happening for them in different contexts and begin to understand more about how and why they react to certain triggers. They can then learn to find alternative ways to think about their problems and create their own solutions with the adult guiding them along the way.

However, how is such a focus on the way feelings, thoughts and behaviours are linked together possible with young children, who are perhaps not able to express their thoughts or feelings verbally?

In adaptations of CBT for use with children, play is used in various activities to help explain some of the issues in a simpler and more meaningful way. For example, through an activity such as using a pair of coloured glasses to look at different objects, a child can begin to understand how we might ‘distort’ things ourselves when we experience certain situations.

Play is, in effect, a symbolic language: a means of communication by which children can express themselves without necessarily having to use words. Through play, children can communicate their understandings and stories about their worlds and reshape their experiences as a natural way of recovering from daily emotional upheavals. Play can therefore have a very powerful therapeutic effect as a vehicle that trained personnel can use to help channel thoughts and emotions, including in very distressed young children.

Figure 4 Play therapy

Show description|Hide description

This is a photograph of a child playing.

Figure 4 Play therapy

Through play therapy, the practitioner enables both a structure to the session as well as the creation of a ‘safe space’ to work through powerful emotional reactions. The practitioner (such as a counsellor) will carefully observe the objects the child chooses to use in their play, the ways in which they use these objects and how the child interacts with the counsellor through play.

Children often find it easier to talk while they are playing. In a play-based therapy a practitioner uses a range of toys, books or other activities as a way of encouraging children to communicate their feelings and thoughts. The therapist will listen and observe the child during a play therapy session. In Session 5 you examined the importance of listening to children, the points covered included:

• the importance of listening to the ‘whole child’, not just what they say verbally
• keeping the child at the centre of the listening process
• allowing the child to take the lead
• how listening was related to the processes of attachment and attunement.

Attunement can be perceived as the art of reading body language, reading what the child is doing in their attempt to communicate with us. As adults, we need to feel open to what children are saying, demonstrating and expressing. Then we can affirm what they have said by repeating their expressions and body language so that we are ‘in tune’ with what they want us to see, rather than what we think we want for or from them.

Activity 2 Counselling children through play therapy

Timing: Allow about 20 minutes

As you listen to Christine (who is a play therapist) in the following video clips, consider how she is explaining the art of listening to children and how she allows the child to take the lead in the counselling process.

You might want to watch all the video clips at once or just dip into each as and when you want to.

Download this video clip.Video player: Video 1

Show transcript|Hide transcript

Transcript: Video 1

CHRISTINE

So partly intuitively, partly through the training, I've always wondered about the child and felt that whatever a child brings and whatever behaviour they show to us as adults, there is a reason for that. So I've always been very curious about that.

So in fact, any approach, or every approach, I have with a child or with a young person is, tell me about you. What's it like? I want to understand. What's it like to be you?

Because that's different for every single one, and we mustn't assume because of the experiences that I have had that the child will have the same experiences. Quite the opposite. So I'm always very, very mindful of that. And it really doesn't matter how old the child is. That applies to the 18-month-old toddler to the 18-year-old who is just leaving home.

Mostly, when children are able to communicate with us verbally, we obviously then use emotional words. And I check the children have the same understanding of that, or at least I'm curious of what their understanding of a word, an emotional word, is. With younger ones, it's more about watching and observing their reactions and their interactions with other people.

What I always feel and go to real length to explain to young people is when I first meet them here in this room is that I'm different to a teacher or a doctor. I'm not here to fix anything. I haven't got a magic wand. But I can be another adult who will listen to them and who will be alongside them.

I bear in mind that a child is always referred to me by an adult. So that's always sort of this-- I'm wondering, do you actually want to be here? Do you know what's going to happen here?

So explaining to a young person-- and I'll call a young person or child, whichever way is appropriate to them-- that I haven't got an answer, and I'm not a teacher who has to write a report, or I'm not a doctor who's going to give medication and medicines. But I'm going to make every effort, and I'll try my best, to help them become a little bit of an expert on themselves so that they can understand what makes them angry, why they're angry, what makes them frustrated or anxious. So that's how I explain to a young person what my role is and how it is different from the adults that they may have in their lives.

End transcript: Video 1

Download

Video 1

Interactive feature not available in single page view (see it in standard view).

Download this video clip.Video player: Video 2

Show transcript|Hide transcript

Transcript: Video 2

CHRISTINE

When I start working with a child-- I always use the word working with a smile in my head, because I don't feel it is work because very often I just am with a child. I just spend time with them. And we play, and we talk, and we explore things.

The guiding principle for me is the acronym PACE. P for playfulness, A for acceptance, C for curiosity, and E for empathy. Not necessarily in that order, but somehow in the session those four words always stay in my head.

So if I go with acceptance, no matter what the child decides and says, it's right for them because it's their truth. Empathy is actually quite a loaded word, but I think of that more as being attuned to a child. So I can really observe the nuances in their reactions sometimes when they don't say anything or do anything. That's communication. And I need to be and feel I can be attuned to them.

And we also know that playing and playfulness is actually a child's work. So it's important that they have things in the room where they can play. And to build that initial relationship with the child, I play with them. As much as I observe them, I am very aware that a child of even a very young age observes me.

They need to come away with a sense of, oh, this is a trustworthy adult. Not that they'll have that cognitive ability to come to that conclusion, but their sense is she's a nice lady. She's a good person. That's what I want to be for them. And I'm aware that a very young child will also go out of this room at the end with a sense of who is this person.

And the curiosity, that's become my language with them. I wonder what it feels like. I'm curious. So there isn't, I think you feel happy, I think you feel cross. I'm wondering. And that opens up that communication with the child to show me, tell me. And I observe. So that, I think, sets me as a counsellor apart from any other professional that a young person has in their lives.

End transcript: Video 2

Download

Video 2

Interactive feature not available in single page view (see it in standard view).

Download this video clip.Video player: Video 3

Show transcript|Hide transcript

Transcript: Video 3

CHRISTINE

So when a child or young person first comes to the room to meet me, it's with the parent. I invite the parent. I really would like-- I like the parents to be in the room first because that's when I tell them about the confidentiality and the permission.

I want parents to give, very, very explicitly, permission to the child to bring anything they want into this room and that I won't feed back to anyone. I won't share what the child says. And the parents need to be comfortable with this, and I want the child to hear the parents say that.

In many cases, the first session is also about getting a little bit of the backstory, what brings them here. And again, I do this very deliberately, with the parent and the child in the room. Although, I may brief the parent to be mindful of the child's feelings, and if there was anything in more depth that we should discuss that I would invite them to do that either by email or by phone or in a separate meeting.

So that gives the child the sense of I am the one who matters. Because that's-- I go to great lengths to explain that this is the child's time and this is about them, as I have this in my head-- I want the child to feel empowered.

You know, a lot of the time, the reason for children being brought to counselling is because either they've become a problem in the family or they're the naughty ones. They're the difficult ones. And of course, that's how they might present, but for me, it's why? What lies behind that? And how can a five-year-old or a six-year-old really be the problem in the family? So I want to-- I have that in my head. I have that in what I focus about when I see them.

Very often, then, and depending on how confident the child is, I will invite them to stay with me on their own for 10 minutes. I'll invite parents to go out of the room to sign that form that we all need to have signed, and then I'll just check in with the child. Are they feeling comfortable with me? I'll explore the room with them. I'll take them on a little tour of the room. But I get a sense, then, are they actually happy to stay here and are they comfortable?

So that's the first phase. We then agree with the parents that the contract, if you like, is with the child in terms of what we talk about, and what we do is ours. But it's obviously the parent who has to agree to bring them on a regular basis and to make payment and all the kind of-- that side of thing. That's their job, and the child's and my role is kind of a three-way contract.

End transcript: Video 3

Download

Video 3

Interactive feature not available in single page view (see it in standard view).

Download this video clip.Video player: Video 4

Show transcript|Hide transcript

Transcript: Video 4

CHRISTINE

The way I section the counselling is in three phases. The assessment phase and the initial phase is when I meet with a parent to get the backstory and to explain what I can offer. The middle phase is then about the actual work with the child. So the child, for example, who is angry, we look at how we understand that anger a little bit better and how we can express it safely.

So that's the actual work we do. It may not be explicit. You were angry, you need to do point 1, 2, or 3. It's through the process of spending time with the child and getting them to explore their reactions. And that's by playing games. How do they feel about winning? How do they feel about losing? That's the middle phase.

That takes as long as it takes. There is no limited or prescribed amount of time. But as is always the case with counselling and therapy, we need to be mindful towards ending therapy. It's bittersweet for us as counsellors because we build a relationship with the young people. But I'm also very aware that when it comes to that third phase, towards ending, beyond therapy, then that the child has become more able to understand themselves better.

I like to feel, and I use the expression sometimes quite deliberately, that the child has become an expert on themselves a little bit more. It's always a lifelong thing. But when I feel, or when together we feel the child has got some tools and strategies that they can apply outside of the room, then we work towards the ending.

End transcript: Video 4

Download

Video 4

Interactive feature not available in single page view (see it in standard view).

Download this video clip.Video player: Video 5

Show transcript|Hide transcript

Transcript: Video 5

CHRISTINE

The room is set up on the face of it when you first walk in, I guess, it's just a bit cluttered, if you like. But there is method in that madness, because obviously a lot of thought has gone into what would help a child first of all feel comfortable and relaxed. And as I said earlier, playing is part of a child's world.

And so I very deliberately have a variety of things in the room. One easy way of describing that perhaps is that I was very mindful of the senses. So I want children to be able to experience and explore through a variety of media. So some child might be very tactile, so there are things in the room that they can really handle and play.

So there's Play-Doh, there's sand. It's on the line of children being able to feel something in their hands. There are also some materials in the room where it allows the child to express themselves through art, either by using paints or the whiteboard. Sometimes, children really like to doodle and to draw.

And together, we can then explore what that means, what they're trying to tell me or themselves. Sometimes, they discover things for themselves. It's about that, too. There are other things in the room where we perhaps go more into the sense of relational games and activities.

Those games can be really quite fun. We laugh. We are noisy. We express our frustrations. And it's something where we can be quite competitive, even. But it is something where we are together.

End transcript: Video 5

Download

Video 5

Interactive feature not available in single page view (see it in standard view).

Download this video clip.Video player: Video 6

Show transcript|Hide transcript

Transcript: Video 6

CHRISTINE

For me, the most important thing in my work with the children is to be with them, to spend time with them where they are not guided, where they are not interrupted, where there isn't an agenda, where there isn't a lesson plan. We can just make it up as we go along and be free with free play, free flow play.

What else is there? Puppets and soft toys, some children really, particularly those who don't want to tell their story directly might feel more comfortable using puppets. So using a puppet to then use them in front of their face and give them a voice.

And sometimes, they talk to me, and I have a puppet. So it's like two puppets interacting. And that's the skill, then, really, and the joy of responding to whatever the child brings.

End transcript: Video 6

Download

Video 6

Interactive feature not available in single page view (see it in standard view).

Download this video clip.Video player: Video 7

Show transcript|Hide transcript

Transcript: Video 7

CHRISTINE

If children want to build something, I've got LEGO. And LEGO is something that they really, really love. That means they are really fully engaged with the LEGO, but I go with them. I go out on the floor alongside them, and I then really have a sense I am just in tune with the child.

Not just the LEGO. I invite children to take things off the shelf. There is a curiosity basket, I call it, with all sorts of odd things in there. And I ask, invite the child to bring it down on the floor together on the floor. We empty it, or I watch what the child brings out, and something always develops. And just spending time being together is so important.

So I like the idea of making something for children to be able to have something tangible when they talk about feelings. So using something like this toy works really quite well. So the idea is that a child has a worry. The worry is written on a piece of card.

And then it's put inside that toy's tummy so that it can be eaten and gone. Because very often, feelings stay as thoughts in a child's head, but they haven't got the tools to deal with that. But physically putting it somewhere works really, really well.

End transcript: Video 7

Download

Video 7

Interactive feature not available in single page view (see it in standard view).

Download this video clip.Video player: Video 8

Show transcript|Hide transcript

Transcript: Video 8

CHRISTINE

I remember when I was still at school, I persuaded senior management that they allow me to take Sammy to school because he's just such a lovely dog. And they agreed.

And what happened was that a young girl, very sadly, her father had died very suddenly. And she came to my office, and Sammy was in my office. And she just sat by him on the floor and eventually fell asleep with her head on Sammy's shoulder. And she then went home and just felt-- and said to mum how she loved and how that was so, so calming for her to be able to just be allowed and to just lie on Sammy.

So that really is when the idea of wow, Sammy's so good with that started. And I looked into pets are therapy more and using animal-assisted therapy. And so I explored that in more detail.

And what I found was that Sammy-- and not just Sammy. I guess it works with other therapy dogs. A child, for example, who isn't very confident, would speak very quietly, very softly, or not at all to anyone in school or even in the family. But when they were with Sammy, I've discovered that they'd all of a start sudden start talking with them. And we would do things like, well, would you like to give Sammy a treat? But then I could, with that, encourage the child to praise Sammy for sitting nicely and for lying down or giving the paw.

So although I wouldn't use the word "become more assertive" with a child, but that's what happened. The child's voice became louder. The child's voice became stronger and more positive. So because Sammy is this beautiful dog, unconditional love, unconditional, it gave that child that confidence and that boost.

End transcript: Video 8

Download

Video 8

Interactive feature not available in single page view (see it in standard view).

Download this video clip.Video player: Video 9

Show transcript|Hide transcript

Transcript: Video 9

CHRISTINE

A really deep observation I found was that a child was more able to identify feelings or states of being in Sammy than in other beings, in human beings, in friends, or family. So Sammy would lie totally relaxed, sleeping, and the child would notice that Sammy is calm, and he's relaxed.

So I could then make the link with, well, what is it like for you to be calm and relaxed? What do you do to be calm and relaxed? And the opposite, when Sammy was excited because he knew there was a treat coming, that liveliness.

So Sammy became this-- or is and continues to be this intermediary between the child and the world, if you like. And it is a real, real lovely way of helping a young person to just discover by observing, to discover their own feelings and their own emotions by observing and describing that of Sammy.

End transcript: Video 9

Download

Video 9

Interactive feature not available in single page view (see it in standard view).

After watching the video clips, note your responses to the following questions:

• How would you describe the key aspects of the counsellor’s approach to working with children explained in the videos?
• In what ways does Christine suggest her role is different from other adults who might be supporting children?
• What processes were described in each of the three counselling phases Christine mentioned?
• How did Christine explain the ways in which she uses her therapy dog, Sammy?
• Which activities demonstrated by the counsellor interested you the most?
• Why do you think that was?
• How do you think children would respond to the different activities?

To use this interactive functionality a free OU account is required. Sign in or register.

Interactive feature not available in single page view (see it in standard view).

Discussion

In the video clips you will have noticed how Christine, the counsellor, stresses how she keeps the child at the centre of her focus and is very much guided by what the child chooses to do. Christine’s role is more of a ‘watchful presence’, allowing the child to explore their environment and their feelings and reactions while she ‘actively listens’ to what they can share with her. These processes may well remind you of the role of the adult listening to children in early years’ settings, as you explored in Session 5.

Creative art-based therapies are increasingly being used to help refugee children traumatised by the effects of conflict and crisis to express their feelings and narrate their own experiences (Tyrer and Fazel, 2014).

Figure 5 Illustration by a Syrian refugee child – David Gross

Show description|Hide description

This is a drawing of a refugee camp using crayons.

Figure 5 Illustration by a Syrian refugee child – David Gross

As you heard from the counsellor in Activity 2 and elsewhere in the course, art materials and creative processes can allow children to come to terms with emotional conflicts, develop greater self-awareness and social skills and encourage more effective coping strategies. They can help to increase self-esteem, reduce anxiety and enable children to learn various problem-solving skills.

Can you also see how use of such materials and therapy with refugee children might help them feel a sense of control over their environment, and enable them to reform a sense of who they are after experiencing the multiple losses that you read about in Session 4?

A qualified art therapy is a more recent intervention in places like Lebanon. Here is a link to a news feature about some of the positive work that is being done with children and their parents there:

News Feature on use of art therapy in Lebanon (make sure to open the link in a new tab/window)

You will notice how parents are being encouraged to mirror their child’s drawings as a way of becoming more attuned to what their children are attempting to express about the experiences they have had.

For some children who have been diagnosed with selected mental health conditions, the symptoms may best be managed by introducing medication. Medication in the field of child and adolescent mental health is almost always recommended to be used in combination with other interventions, such as evidence-based psychotherapies like CBT. The decision to prescribe medication is a significant one and is usually only considered after a thorough assessment and when other interventions on their own are not making a sufficient difference to the child’s symptoms. Medication is prescribed by a medical doctor, usually a child or adolescent psychiatrist working in CAMHS, and the decision to do so should be in consultation with the child and their parents or guardians, frequently with input from other professionals involved in the child’s care.

Prescription of medication is limited in the child and adolescent mental health field, but when used it is important that the child is reviewed regularly to assess for possible side effects as well as improvements. For example, an older child with moderate or severe and persistent depressive symptoms may be prescribed an anti-depressant frequently alongside other interventions (National Institute for Clinical Excellence, 2019).

Figure 6 Child receiving medication

Show description|Hide description

This is a photograph of an adult’s hand holding a spoonful of medicine, with a child in the background.

Figure 6 Child receiving medication

The most common conditions in the child and adolescent mental health field where medication is prescribed are for severe ‘treatment resistant’ depression, attention deficit hyperactivity disorder (ADHD) and (in older adolescents and adults) psychosis.

It is important to note that there is varying guidance about the prescribing of medication for very young children; some medication is not licensed for children below a certain age. The National Institute for Clinical Excellence (NICE) is part of the Department of Health in the UK and it produces guidance that is based on evidence about a wide range of health treatments and approaches to management.

Further information about prescribing medication for children with mental health conditions can be found in NICE guidance. You can find the details of some of this guidance in the ‘Further reading’ section at the end of the session.

There are of course pros and cons relating to the administration of drugs to manage symptoms of mental ill-health. Some medication is not prescribed, but are still ‘psychoactive drugs’ (i.e. is a chemical substance that changes brain function) nonetheless. For instance, when parents give their children ‘natural remedies’ such as St John’s wort, usually without any medical advice.

Activity 3 The advantages and disadvantages of medication for children with mental illness

Timing: Allow about 15 minutes

Consider the pros and cons, or advantages and disadvantages, of prescribed medication when recommended by a medical doctor for a child who has been diagnosed with a mental health illness. Think about the possible advantages and disadvantages for the child, the family, their education setting.

Figure 7 Examining the different perspectives of prescribing medication

Show description|Hide description

This is a graphic with a number of circles. In the central circle is the text ‘medication for a child with a mental health illness’. The other circles branch out from the central circle, and they contain the following text: ‘child’; ‘community and society’, ‘education setting’ and ‘parents and siblings’.

Figure 7 Examining the different perspectives of prescribing medication

To use this interactive functionality a free OU account is required. Sign in or register.

Interactive feature not available in single page view (see it in standard view).

Discussion

Here are some of the advantages and disadvantages of prescribing medication. You may have identified others.

The child

Advantages: Prescribing medication can help to address symptoms or features of a disorder and enhance a child’s functioning. For example, a child who has been diagnosed with attention deficit hyperactivity disorder (ADHD) after a comprehensive assessment across a range of environments, including their home and school, may find that medication, in particular Ritalin, can help to reduce their impulsive behaviour. Burton et al. (2014) illustrate this point by recounting their experience of working with children who report that an advantage of taking medication in this context is that it gives them ‘thinking time’ (p. 30), meaning that the medication can help increase their concentration. Increased concentration can help children to better engage with their education and learning.

Disadvantages: Not all medication works in the same way, and for some conditions efficacious medications are not available. Plus, we are all individual and dosage and personal preferences are important. Unfortunately, it is not uncommon for medications to cause side effects. This is why, prior to being prescribed a medical doctor will do a careful ‘cost-benefit analysis’ to determine whether the possible advantages (or benefits) clearly outweigh the costs (such as the side effects). Children who have been prescribed medication for ADHD may experience sleep problems, headaches and mood swings (National Health Service, n.d.). But without their medication they may struggle to function adequately, disrupting their learning and negatively impacting on their relationships with others.

When medication is having a positive impact there are also disadvantages. A compromise may be reached by introducing what Pavord et al. describe as treatment ‘holidays’ (2014, p. 30). This is where, for example, the child may take a break from medication when they are not at school.

Parents

Advantages: Having a child with a mental health condition can be distressing for parents and the whole family. The symptoms of a mental illness can have a profound impact on parents, who frequently blame themselves for their child’s diagnosis, which can be difficult for them to manage. Prescribing medication occurs infrequently with younger children, and should always be done when it is in the best interests of the child. Reducing symptoms and improving functioning as a result of medication can mean that parents will experience less pressure and in turn it makes parenting a ‘challenging child’ less difficult. Reducing the pressure on the family can help make a positive contribution to the wellbeing of parents and other siblings.

Disadvantages: Parents may find that medication, in particular the treatment adherence associated with it, becomes an added task which requires extra effort and time. This can include remembering to order the medication, administering it suitably, liaising with the child’s education setting and taking the child to review appointments. Some parents may have cultural or religious beliefs that mean they are reluctant for their child to receive medication, and many parents will be opposed to their child taking medication because they would prefer talk-based therapy.

Education

Advantages: If the medication assists the child, in terms of their functioning, this can mean that the child is able to more fully participate in their education setting. This has advantages for the child, and potentially for other children and for the staff.

Disadvantages: Staff may need to be aware of potential side effects of medication. Learning about this will require time to access training and to be able to liaise with parents. Some medication is formulated so that it can be given at home; however, this may not always be the case, therefore a medication policy will need to be written. Consideration will need to be given about the storage and administration of medication and who at the school is responsible for this.

Prescribing medication needs to be a joint decision, as far as possible. It is important to review the impact of the medication and to weigh up the pros and cons. Of course, not all medication is prescribed – ‘natural remedies’ purchased over the counter also carry risks, and there is limited evidence to support their effectiveness.

The UK government’s green paper ‘Transforming Children and Young People’s Mental Health Provision’ states that:

Therefore, a growing body of training for staff is now becoming available to help develop more effective strategies for dealing with various mental health issues in children and young people. Staff are also being encouraged to become more vigilant (on the alert) and proactive (prepared to act) in response to potential triggers and stresses that might lead to mental health problems.

You have already examined many of the issues that affect children’s mental wellbeing throughout the course so far. Can you recall some of these?

You may have thought of the following:

• bullying
• loss, including the death of significant carers, siblings, friends
• parental separation
• physical, emotional and sexual abuse
• neglect
• personal and family illness or disability
• frequent house moves
• living in poverty
• lack of financial stability and resources at home.

Trauma-informed practice means that everybody within an organisation such as a school – from administrators to governors, teachers and parents – can understand, recognise and respond to the effects of all types of trauma.

You might like to look at the following website to see the kind of training that might be involved, and how such training relates back to many of the issues around supporting children’s mental health and wellbeing that have been addressed in this course to date:

Trauma informed schools (make sure to open the link in a new tab/window)

Activity 4 Trauma-informed practice

Timing: Allow about 10 minutes

Watch the two clips of Christine describing her personal journey from teaching in school to counselling children.

As you watch the clips, reflect on what Christine found difficult about the school system, and how perhaps with more effective training in trauma-informed practice as discussed previously in this session, the situations Christine described might be better supported.

Download this video clip.Video player: Video 10

Show transcript|Hide transcript

Transcript: Video 10

CHRISTINE

I've always wanted to work with children. So I started my career, my first career, as a class teacher teaching languages. Notoriously difficult subject to teach, but I became very interested in working with children, and I also then wanted to understand children better.

So I took an interest in a pastoral role, and I became a year leader, a head of year, for Year 7. So that's the transition from primary to secondary school. And that really gave me the first insight and the very big privilege of getting to understand sort of stories behind the children and their families. And it really started with that.

I then became curious. I wanted to know more about how children develop, child development as a whole. And I started reading. I started talking to people, to professionals, such as educational psychologists, assistant head teachers, just some inspirational professionals. That's how I started to then think, hmm, I want to learn a little bit more about that. So I started to train. And I trained as a counsellor and therapist.

And also, I then felt that I had-- I call it a gift, but I had a way of connecting with younger people probably a little bit easier than adults, if you like. So I found that they started telling me stories about them.

And I remember a particular incident with a teenager, probably 13, 14 years of age. And we were just chatting in my office, and she said, you are the only one who really gets me, the only adult who gets me and who under-- how do you know this is how I feel? So that is one of the key moments that stayed with me, that made me think, I want to do a bit more than that.

End transcript: Video 10

Download

Video 10

Interactive feature not available in single page view (see it in standard view).

Download this video clip.Video player: Video 11

Show transcript|Hide transcript

Transcript: Video 11

CHRISTINE

And then I also felt as I had a responsibility for the pastoral welfare. And I took those two words very seriously, pastoral and welfare. I felt that the system, the school, the education system I was part of, was very constrictive and restrictive and actually very punitive. So children who would break the rules, we have to punish them. We have to tell them that that was wrong. But I wanted to differentiate. I wanted to understand why some children broke rules and what sat behind that.

So more and more, I became kind of a little bit-- not so-- subversive is not quite the word, but I tried to do things slightly differently for children. I wanted to protect them from the system, if you like. So I just took every opportunity I had to talk with young people.

There's another story I'll share with you, and that is I was walking-- in the school, we had a long, long corridor-- and a young girl walked by. As always, I acknowledged her. You OK? She said, yeah, I'm fine. But I wasn't convinced that she was fine, so I just sort of reflected, mm-mm, didn't sound quite right, invited her back to my office. And almost immediately she disclosed that she had been to the toilets to self-harm.

So that is just really the beginning of a long story then. I was able to signpost her and to get her the support and help she needed. And those two incidents really made me feel that's what I want to do more, work and support young people in a more long-term sustained way. That's what got me into counselling and therapy.

End transcript: Video 11

Download

Video 11

Interactive feature not available in single page view (see it in standard view).

To use this interactive functionality a free OU account is required. Sign in or register.

Interactive feature not available in single page view (see it in standard view).

You may have heard the comment that, unlike items such as a washing machine, babies do not arrive with an instruction manual. Professional support for parenthood is part of the antenatal care available to pregnant women, and included in antenatal care are practices that are aimed at maximising the chances of strong attachment bonds forming between the baby and parent(s).

Every child born in the UK has a health visitor assigned to them. Part of the health visitor role is to provide support and guidance to parents about their children’s health and development. Session 6 included some information about the role of the health visitor.

Despite the professional support that is available, a shortage of services in some areas and other factors can mean that some parents find parenting a challenge and would benefit from further support. An area of challenge for many parents is their children’s behaviour. Many parents struggle when their children’s behaviour is deemed to be unacceptable both by themselves and others. Support for such parents is available via parenting programmes. However, the reduction in the number of children’s centres has affected the availability of such parenting courses in many areas. Furthermore, professionals need to be careful that deficit models of parenting are not the focus of support programmes and workshops. Deficit models can make parents feel inadequate and undermine perceptions of the family as a whole system with varying strengths, weaknesses and levels of resilience.

Burton et al. (2014) summarise the key objectives of parenting programmes, which are to:

• promote positive parenting
• improve parent–child relationships
• help parents to manage their children’s behaviour
• reduce the need for discipline and increase the use of positive strategies.

There are several parenting programmes which have been evaluated positively and are evidence-based, such as ‘The Incredible Years’. Programmes such as this one have proven to show significant improvements in children’s behaviour and these ‘parent management training’ interventions are the treatment of choice for children with conduct disorder. A Public Health England (2014) publication includes more information about parenting programmes. There are features of parenting programmes that are essential for the programme to be effective and have a positive impact on the child and family:

• group based: giving parents the opportunity to discuss and learn from each other.
• strengths based: all parents have strengths, and these should be identified and built upon.
• use of a manual: parenting programmes should have a manual that is referred to and used in the classes.
• homework: parents should have tasks to carry out at home to reinforce messages from the parenting classes.
• role play: opportunities to practise skills.

At the end of each session, you should take some time to reflect on the learning you have just completed and how it has helped you to understand more about children’s mental health. The following questions may help your reflection process each time.

Well done – you have reached the end of Session 7. You can now check what you’ve learned this session by taking the end-of-session quiz.

Session 7 practice quiz

Open the quiz in a new tab or window and come back here when you have finished.

In this session, you have focused on various interventions that can be useful when trained specialists work with individual children and their parents in helping to improve children’s mental health and wellbeing. You have also seen how prescribed medication can sometimes be administered but needs to be undertaken very carefully according to clinical guidelines, such as those developed by NICE. There is also a growing acceptance that children’s wellbeing needs to be the responsibility of everyone who works or is involved with children in a variety of settings, and at different levels within an organisation.

You should now be able to:

• recognise how the power imbalances between child and adult can affect the therapeutic processes
• understand what is meant by cognitive behavioural therapy (CBT)
• appreciate the role of play and creativity in counselling and therapy with young children
• realise some of the challenges associated with prescribing medication to treat a child’s mental health condition
• understand how parents might be helped to manage children’s behaviour and support their wellbeing.

In the next session, which is the final session of the course, you will be examining the effects of technology on children’s mental health. You will also review the key messages you have hopefully gathered from all of the sessions in this course.

You can now go to Session 8.