Treatment Options Explained
There are many treatment options available for children and their families. Some of these include:
- Behavior Therapy
- Cognitive Behavioral Therapy (CBT)
- Trauma Focused Cognitive Behavioral Therapy (TF-CBT)
- Exposure Therapy
- Expressive Therapy
- Interpersonal Therapy (IPT)
- Family interventions, which include:
- Intensive home and community-based interventions, which include:
(Much of this information came from NAMI, the National Alliance on Mental Illness)
Behavior therapy helps a child or adolescent change negative behaviors and improve behaviors in school, at home, and with peers through a reward and consequence system. In behavior therapy, goals are set for the child and small rewards areearned for positive behavior. Children may also lose privileges or be put in time-out for a brief period for failing to meet expectations, although the primary therapeutic focus is on reinforcing positive behavior by rewarding the young person with gold stars, extra computer time, and other earned privileges.
For children with attention deficit/hyperactivity disorder, some simple behavioral interventions at home might include setting and maintaining a consistent daily schedule and routine for the child. This includes a schedule for homework, playtime, meals, and sleep. The schedule should be posted and clearly visible to help the child succeed. Everyday items that a child uses—such as clothing, a book bag, lunch, and others—are organized in a way that helps the child meet his or her goals and achieve success. At school, behavioral interventions might include developing a daily report card to provide the student with regular feedback and using a point or token system to reward positive behaviors.
Families play an essential role in developing goals for their child and in administering the reward and consequence system. In behavior therapy, the parents function as co-therapists by carrying out the behavior management plan that is developed by the parents and therapist together. The behavior therapy targets the child by helping parents and teachers apply skills that will benefit the child, including those related to communication, conflict reduction, ignoring some behaviors, and rewarding others.
There are a number of effective behavioral interventions for children and adolescents.
Average Length of Treatment: Depends on the unique needs of the child, may be ongoing.
Effective For: Attention Deficit/Hyperactivity Disorder, Oppositional Defiant Disorder, Conduct Disorder, and Autism.
CBT teaches youth how to notice, take account of, and ultimately change their thinking and behaviors that impact their feelings. In CBT, youth examine and interrupt automatic negative thoughts that they may have that make them draw negative and inappropriate conclusions about themselves and others. CBT helps a young person learn that thoughts cause feelings, which often influence behavior.
The therapy targets and works to stop negative thoughts. For example, if an adolescent did poorly on a test and is thinking “I’m dumb and worthless” CBT helps that young person identify how to think and act more positively to perform better on the test, rather than focusing on negative thoughts about him or herself.
CBT helps children and adolescents to improve their coping and problem-solving skills. It also encourages them to increase their involvement in enjoyable and healthy activities.
Those participating in CBT are typically given homework with the expectation that the child is working outside of the office. Family involvement in CBT includes parents reinforcing more sensible and positive thoughts and helping the child practice this new way of thinking outside of the clinician’s office.
Average Length of Treatment: 12 to 16 weeks, with a 60–90 minute session each week.
Effective For: Anxiety, Depression, Oppositional Defiant Disorder, Conduct Disorder, and Trauma.
TF-CBT is for children affected by sexual abuse and/or trauma. It is designed to reduce negative emotional and behavioral responses following child sexual abuse, domestic violence, traumatic loss, and other traumatic events. The treatment—based on learning and cognitive theories—addresses distorted beliefs and attributions related to the abuse and provides a supportive environment in which children are encouraged to talk about their traumatic experience. TF-CBT also helps parents who were not abusive to cope effectively with their own emotional distress and develop skills that support their children.
Components of the TF‐CBT protocol can be summarized by the word PRACTICE
P - Psychoeducation and parenting skills—Discussion and education about child abuse in general and the typical emotional and behavioral reactions to sexual abuse; training for parents in child behavior management strategies and effective communication
R - Relaxation techniques—Teaching relaxation methods, such as focused breathing, progressive muscle relaxation, and visual imagery
A - Affective expression and regulation— Helping the child and parent manage their emotional reactions to reminders of the abuse, improve their ability to identify and express emotions, and participate in self‐ soothing activities
C - Cognitive coping and processing— Helping the child and parent understand the connection between thoughts, feelings, and behaviors; exploring and correcting of inaccurate attributions related to everyday events
T - Trauma narrative and processing— Gradual exposure exercises, including verbal, written, or symbolic recounting of abusive events, and processing of inaccurate and/or unhelpful thoughts about the abuse
I - In vivo exposure—Gradual exposure to trauma reminders in the child’s environment (for example, basement, darkness, school), so the child learns to control his or her own emotional reactions
C - Conjoint parent/child sessions—Family work to enhance communication and create opportunities for therapeutic discussion regarding the abuse and for the child to share his/her trauma narrative
E - Enhancing personal safety and future growth—Education and training on personal safety skills, interpersonal relationships, and healthy sexuality and encouragement in the use of new skills in managing future stressors and trauma reminders
Exposure therapy educates and teaches children and adolescents about how to manage fears and worries to reduce their distress. The child is gradually exposed to threatening situations, thoughts, or memories that make the child excessively anxious or worried.
For example, with a child that has an extreme fear of attending school, the therapist might appropriately walk with the child to school and each time get closer and closer to the school, until they eventually enter the school. The therapist gently, persistently, and gradually exposes the child to the situation that causes the extreme fear. During this time, the therapist talks with the child about his or her fear and anxiety and provides therapeutic support.
In Exposure Therapy, the therapist offers the child replacement strategies to reduce anxiety and fear (such as deep breathing, exercise, and talking) with the expectation that the fear will be reduced and ultimately eliminated.
Exposure Therapy helps the child to cope with extreme fears and worrisome situations rather than avoiding them, helps to eliminate distressful thoughts, nightmares, problems focusing, attention, irri- tability, and anger.
Average Length of Treatment: 7 to 15, 90-minute sessions (depending on the severity of the symptoms).
Effective For: Anxiety Disorders, more specifically Phobias.
The expressive therapies are defined in this text as the use of art, music, dance/movement, drama, poetry/creative writing, play, and sandtray within the context of psychotherapy, counseling, rehabilitation, or health care. Several of the expressive therapies are also considered “creative arts therapies”—specifically, art, music, dance/movement, drama, and poetry/creative writing according to the National Coalition of Creative Arts Therapies Associations (2004a; abbreviated as NCCATA). Additionally, expressive therapies are sometimes referred to as “integrative approaches” when purposively used in combination in treatment.
While expressive therapies can be considered a unique domain of psychotherapy and counseling, within this domain exists a set of individual approaches, defined as follows:
- Art therapy uses art media, images, and the creative process, and respects patient/client responses to the created products as reflections of development, abilities, personality, interests, concerns, and conflicts. It is a therapeutic means of reconciling emotional conflicts, fostering self- awareness, developing social skills, managing behavior, solving problems, reducing anxiety, aiding reality orientation, and increasing self-esteem (American Art Therapy Association, 2004).
- Music therapy uses music to effect positive changes in the psychological, physical, cognitive, or social functioning of individuals with health or educational problems (American Music Therapy Association, 2004).
- Drama therapy is the systematic and intentional use of drama/theatre processes, products, and associations to achieve the therapeutic goals of symptom relief, emotional and physical integration, and personal growth. It is an active approach that helps the client tell his or her story to solve a problem, achieve a catharsis, extend the depth and breadth of inner experience, understand the meaning of images, and strengthen the ability to observe personal roles while increasing flexibility between roles (National Drama Therapy Association, 2004).
- Dance/movement therapy is based on the assumption that body and mind are interrelated and is defined as the psychotherapeutic use of movement as a process that furthers the emotional, cognitive, and physical integration of the individual. Dance/movement therapy effects changes in feelings, cognition, physical functioning, and behavior (NCCATA, 2004b).
- Poetry therapy and bibliotherapy are terms used synonymously to describe the intentional use of poetry and other forms of literature for healing and personal growth (NCCATA, 2004c).
- Play therapy is the systematic use of a theoretical model to estab- lish an interpersonal process wherein trained play therapists use the therapeutic powers of play to help clients prevent or resolve psychosocial difficulties and achieve optimal growth and development (Boyd-Webb, 1999; Landreth, 1991).
- Sandplay therapy is a creative form of psychotherapy that uses a sandbox and a large collection of miniatures to enable a client to explore the deeper layers of the psyche in a totally new format. By constructing a series of “sand pictures,” a client is helped to illustrate and integrate his or her psychological condition.
- Integrated arts approach or intermodal (also known as multimodal) therapy involves two or more expressive therapies to foster awareness, encourage emotional growth, and enhance relationships with others. Intermodal therapy distinguishes itself from its closely allied disciplines of art therapy, music therapy, dance/movement therapy, and drama therapy by being grounded in the interrelatedness of the arts. It is based on a variety of orientations, including arts as therapy, art psychotherapy, and the use of arts for traditional healing (Knill, Barba, & Fuchs, 1995). (Cathy Malchiodi)
IPT is designed for adolescents with depression. It examines relationships and transitions for adolescents, and how they affect a youth’s thinking and feeling. IPT focuses on the adolescent and helps them manage major changes in their lives, such as divorce and significant loss, including the death of a loved one. In IPT, a therapist examines one or more of four areas that commonly contribute to a young person’s serious distress:
- Role transition and changes in role identity—an example may be when an adolescent is asked to leave a sports team or becomes pregnant
- Role dispute and authority conflicts—an example may be when a parent insists that a young person complete homework and that person wants to do something else
- Grief and loss—may be related to divorce or the death of a loved one; and
Interpersonal conflict and peer relationships.
In IPT, the therapist helps the adolescent evaluate his or her relationships and interactions with others. This is an effective form of therapy, however, few providers are trained in IPT so it may be challenging for families to access IPT treatment for their child. Studies show that IPT reduces depression in youth and improves social and problem-solving skills.
Average Length of Treatment: Approximately 12 weeks, with weekly face-to-face sessions and with regular telephone contact.
Effective For: Depression.
Evidence-based family interventions include family therapy, parent training, family education, and support. These interventions recognize the important role of families in helping a child who is struggling with mental health disorders, substance use, and/or disruptive behaviors. Family-based treatments involve parents and caregivers as essential partners and recognize that they need special skills to address their child’s challenging emotions and behaviors. The following are evidence-based family interventions.
BSFT focuses on improving the interactions between the family and the child. This intervention creates a positive relationship between a counselor and the whole family by looking at family strengths and conflicts in interactions between family members. This allows the counselor and family to develop and implement strategies that build on family strengths to correct problems. Therapeutic strategies include building conflict resolution skills, providing parent coaching and guidance, and improving family interactions to reduce problem behaviors.
BSFT focuses on family interactions by identifying who was involved in a conflict, when it occurred, who responded to whom, and what preceded and followed the conflict. It does not look simply at what was said, rather at the process of the interaction. BSFT can be done in a community clinic, agency setting, or in a family’s home.
BSFT was developed at the Spanish Family Guidance Center in the Center for Family Studies at the University of Miami and has been tested and shown to be effective with Latino and African American youth and their families.
Average Length of Treatment: 12 to 15 sessions over 3 months, with 60–90 minute sessions.
Effective For: Oppositional Defiant Disorder, Conduct Disorder, and Substance Abuse Disorder.
FFT is a family-focused therapy designed to engage families to decrease the intense negativity in their lives that may include mental illness in a child or parent, school drop out, and substance use. FFT works to motivate youth and families to change behavior. The behavior change comes through skill training in family communication, promoting positive parenting, problem-solving, and conflict management skills.
FFT helps to increase a family’s capacity to use community resources such as schools, case managers, and other child-serving professionals, to support change from multiple systems, and to prevent relapse.
FFT has been a cost-effective alternative for youth involved in the juvenile justice system. It is less costly than restrictive juvenile detention and residential treatment and produces significantly better outcomes in family interaction, reducing recidivism, and improving a young person’s functioning. Several states are engaged in statewide implementation of FFT for youth involved with the juvenile justice system, including Washington, New York, and Michigan. FFT can be delivered in the home, as outpatient therapy in a clinic, or in a juvenile justice facility.
Average Length of Treatment: 8 to 12 one-hour sessions, with up to 30 sessions for more serious cases.
Effective For: Oppositional Defiant Disorder, Conduct Disorder, and Substance Abuse Disorder.
PMT is designed to help parents develop effective child behavior management skills, often for children that have difficult and disruptive behaviors. In PMT, therapists work directly with parents to help them acquire effective skills to use with their child.
Parents are taught how to effectively set limits, enforce conse- quences, reinforce positive behaviors, and enhance behaviors at home and in school. The training programs are individualized for the unique needs of each family. Therapists maintain close telephone contact with families between sessions to help reinforce the skills they have learned, and to be informed about progress and problems that may have arisen. Children and adolescents learn new skills through PMT that help improve their behavior and relationships at home and in school.
Average Length of Intervention: 4 to 6 months, may vary with the severity of need.
Effective For: Attention Deficit/Hyperactivity Disorder, Oppositional Defiant Disorder, and Conduct Disorder.
PCIT focuses on the child and parent. There are two phases to PCIT: one that is child-directed and one that is parent-directed. Both phases are taught in play situations. Parents are observed by a therapist and taught skills to better address their child’s challenging and disruptive behaviors.
In the child-directed phase, the child leads play and parents are coached on how to respond to appropriate behavior and to ignore inappropriate behavior. Coaching is typically provided through a one-way mirror as the parent interacts with the child. The goals of the treatment include: improving the quality of the child-parent relationship, decreasing problematic behaviors, increasing positive behaviors, increasing parent skills, and reducing parent stress.
PCIT is typically used with young children between the ages of three and seven years old.
Average Length of Treatment: 12 to 20 weeks.
Effective For: Oppositional Defiant Disorder.
Play therapy is a form of counseling (or psychotherapy) by which licensed mental health professionals use play-based models and techniques to better communicate with and help clients, especially children, achieve optimal mental health. This may include the use of toys, games, art materials, music, movement, and sensory integration. Play therapy is a structured, theory based approach to therapy that builds on the normal communication and learning processes of children.
Children find playing healing and curative. Therapists strategically utilize play therapy to help children express what is troubling them when they do not have the verbal language to express their thoughts and feelings. In play therapy, toys are like the child's words and play is the child's language. Through play, therapists may help children learn more adaptive behaviors when there are emotional or social skills deficits. The positive relationship that develops between therapist and child during play therapy sessions can provide a corrective emotional experience necessary for healing. Play therapy may also be used to promote cognitive development and provide insight about and resolution of inner conflicts or dysfunctional thinking in the child. (Association for Play Therapy)
Family psychoeducation is an evidence-based practice in adult mental health. The Substance Abuse Mental Health Services Administration (SAMHSA) and Center for Mental Health Services (CMHS) tool kit on EBPs for adults includes resources on family psychoeducation.
Family psychoeducation programs are designed to achieve improved outcomes for people living with mental illnesses by building partnerships among consumers, families, providers, and others supporting the consumer and family. Family psychoeducation programs are often led by clinicians and can also be led by family members. These programs focus on creating an atmosphere of hope and cooperation. Through relationship-building, education, collaboration, and problem solving, these programs help consumers and families to:
- Learn more about mental illnesses and effective treatment options
- Master new and effective ways to manage the illness
- Acquire strategies for handling crises and relapse
- Provide social support and encouragement for each other
- Teach caregivers to reduce stress and to take care of themselves
- Focus on hope and the future
- Help families better understand how to help consumers on their road to recovery.
Research shows that family psychoeducation programs have led to improvements in functioning for adults living with mental illnesses.
In children’s mental health, a limited number of studies have examined the impact of family psychoeducation on children and families. One model of family psychoeducation that has been studied is the Multi-Family Psychoeducation Groups (MFPG) program. The program is designed for families with children with mood disorders, including bipolar disorder and major depressive disorder.
The MFPG program focuses on working with families to identify the symptoms and effective treatment for mood disorders and improving problem-solving and family communication skills. The program also includes sessions with children with mood disorders that cover a number of topics (symptoms, treatment, anger management, the connection between thoughts, feelings, and actions, impulse control, and improved communication skills).
Research on MFPG is ongoing. Positive results have been reported, including increased parental knowledge about mood disorders, increased positive family and child interactions, improved parent coping skills and support, and more. The MFPG developers have received a grant from the National Institute on Mental Health (NIMH) for ongoing research to help develop an evidence base.
There are also family education and support programs developed by family organizations and taught by trained family teachers. NAMI developed the Family-to-Family education program (F2F) for care-givers of adults living with mental illnesses. This education program focuses on strengthening, supporting, and empowering caregivers to help them help their loved ones living with mental illness on their road to recovery. NAMI is working to establish an evidence-base for the Family-to-Family program through a multi-year NIMH grant awarded to the University of Maryland. NAMI is also currently developing a similar education program for parents and caregivers of children and adolescents living with mental illnesses.
Family education and support programs use experienced and trained parents of children receiving mental health services to pro- vide support to other parents. The most common types of support include affirmation and emotional support (empathy, reassurance, and positive regard to reduce distress, shame, and blame), and informational support (about disorders, treatment options, parenting skills, coping techniques, community resources, and stress reduc- tion). In education and support programs, families are highly valued for their expertise in understanding their child and his or her needs.
Family-driven and peer-to-peer education and support programs are receiving increased attention and it is likely that the evidence base will continue to grow for these programs.
Average Length of Program: Varies by program.
Effective For: Preliminary evidence to support use of family psycho-education and support programs for adolescents with Major Depression, Bipolar Disorder, Tourette’s Syndrome, and Anorexia. Preliminary evidence also supports use of family support and education interventions for youth with a mix of disorders—with evidence showing parents and families have a greater sense of understanding and empowerment about services for their children.
It is essential that systems of care in states and communities be developed that include a comprehensive array of services that promise to help prevent out-of-home placement for children and adolescents and provide the services and supports that families need. A national Systems of Care movement has gained momentum over the past decade through a grant program administered by the Center for Mental Health Services (CMHS). Through this program, CMHS provides grants to states, communities, territories, Indian tribes, and tribal organizations to improve and expand their systems of care to meet the needs of children and adolescents with serious mental health treatment needs and their families. These community systems of care programs are a helpful resource for families. The resource section of this guide includes information on how families can learn more about the services and supports available in community-based systems of care grant sites.
The following are some of the evidence-based intensive home and community-based interventions that may be available to children and their families:
Wrap-around is a philosophy of care that includes a definable planning process involving the child and family that results in a unique set of community services and natural sup- ports individualized for that child and family to achieve a positive set of outcomes.
The values that provide the foundation for the wrap-around philosophy of care are interwoven and not mutually exclusive, but together constitute a conceptual framework. These values include:
- Voice and choice for the child and family
- Compassion for children and families
- Integration of services and systems
- Flexibility in approaches to working with families and in the funding and provision of services
- Safety, success, and permanency in home, school, and community
- Care that is unconditional, individualized, strengths-based, family-centered, culturally competent, and community-based with services close to home and in natural settings.
The wrap-around process generally includes four phases.
Phase One Engagement and Team Preparation. In phase one, the family meets with a wrap-around facilitator (person trained in wrap- around) and together they explore the family’s strengths, needs, cul- ture, and goals. They discuss what has worked in the past, and what they should expect from wrap-around. The family recommends other team members, the facilitator engages these members, and pre- pares for the first wrap-around meeting. [Lasts about 2–3 weeks]
Phase Two Initial Plan Development. In phase two, the team learns about the family’s strengths, needs, and goals for the future. The team decides what they will work on, how the work will be accom- plished, and assigns team members responsibility for action steps. A wrap-around plan or plan of care is developed, along with a plan to manage crises that may arise. [Lasts about 1–2 weeks]
Phase Three Plan Implementation. In phase three, ongoing team meetings are held during which the team reviews accomplishments and progress toward goals, and makes necessary adjustments. [Lasts about 9–18 months]
Phase Four Transition. Transition is negotiated with the team once outcomes are accomplished and the team nears its goals. The family and team decide how the family will continue to get support after they have formally transitioned out of wrap-around. The team also establishes how the family will return to wrap-around, if necessary. [Ongoing]
Intensive case management is different from wrap-around services because it generally relies on a single case manager who is assigned to work with the family. The case manager works closely with a child’s family and other professionals to develop an individualized comprehensive service plan for the child and family. These specially trained and qualified case managers assess and coordinate the services and supports necessary to help keep a child at home, in the community, and out of more restrictive treatment settings. Intensive case management defines the caseload size, intending fewer than 30 clients for any one case manager.
As with wrap-around, case managers work with a child and family in one or more of the following areas:
- Care coordination, which is especially important when a child is receiving services from more than one agency—for example: school, a community mental health center, and others
- Interagency collaboration to help ensure that the child is not falling through the cracks and is receiving needed services
- Outreach to agencies that should be involved in the services provided to the child and family
- Monitoring and tracking of service use
- Advocating for effective and appropriate services.
Families greatly appreciate effective wrap-around and intensive case management, because without it, the burden of care coordination falls on families who are often already overwhelmed with their child’s serious mental health treatment needs.
MST is short-term and intensive home-based therapy. MST therapists have small case loads (from four to six families) designed to meet the immediate needs of families. The MST team is available 24 hours a day, seven days a week to work with families.
MST recognizes parents and families as valuable resources, even when they may have serious and multiple needs of their own. MST therapists work to empower families by identifying family strengths and natural supports that may include extended family, neighbors, the church community, school professionals, and others. MST therapists work with the family to address barriers such as: high stress, parental substance use, poor relationships within the family, and more.
The MST team uses evidence-based therapies in working with youth and their families, including behavior therapy, cognitive behavioral therapy, and others. Families take the lead in setting treatment goals and MST therapists help them to achieve those goals. MST also works with the family to develop effective strategies in the following areas:
- Setting and enforcing curfews and rules
- Decreasing youth involvement with peers who have a negative
- Promoting positive friendships and relationships
- Improving school attendance and performance
- Reducing substance use and the need for contact with law
- Relating strategies designed to meet the unique needs of the family.
Research has shown that MST is an effective alternative to incarceration for youth involved in the juvenile justice system. MST helps to reduce antisocial behavior, substance use, and contact with law enforcement. It also reduces the overall cost of services by reducing youth incarceration rates and out-of-home placements.
Average Length of Treatment: four months, with approximately 60 hours of contact with the MST team.
Effective For: Substance Abuse Disorder, Oppositional Defiant Disorder, and Conduct Disorder.
In mentoring programs, an adult with good child relationship skills helps children to increase their healthy activity and involvement in school and the community. A mentor works with a child or adolescent intensively, which may include up to five days a week, and over a long time—up to a year.
Mentoring relationships have a positive influence on the lives of young people, including those with mental health and substance abuse disorders. Mentoring relationships help to improve school performance and behavior, family and peer relationships, self- esteem, and to reduce antisocial behaviors. They also help to reduce youth contact with law enforcement and substance abuse. The essential elements of effective mentoring programs for youth with mental health and substance abuse disorders include training, supervision, and the use of qualified and professional mentors.
Effective For: Youth with serious mental health disorders, substance abuse disorder, or at risk of developing these disorders.
Respite care is a type of family support that provides a family with relief from child care by bringing a caregiver into the home or placing a child in another setting for a brief period of time.
Respite care allows families with a child with serious needs, including mental illnesses, a break from the responsibilities of caring for their child. It can be a regular break for families or to allow time for a vacation. Respite is typically used in a time of family crisis, including a medical crisis of a parent or caregiver. A trained respite care provider, which may be another parent or a professional, takes care of the child.
Respite helps to reduce the incredible stress that comes with caring for a child with serious mental health treatment needs. It also helps to prevent out-of-home placement for children and adolescents with serious mental health treatment needs.
Effective For: Families of children and adolescents with serious mental health treatment needs.