Mental Health for the Young & their Families in Victoria is a collaborative partnership between mental health & other health professionals, service users & the general public.
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Parkville, Vic 3052
PROJECT EVIDENCE for Treatment of Mental Disorders. The project coordinator is Dr Allan Mawdsley. The version can be amended by consent. If you wish to contribute to the project, please email email@example.com
 Standard Treatment
a) Outpatient psychotherapies, medication and procedures
b) Inpatient psychotherapies, medication and procedures
c) Ancillary support services
[6 a ] Outpatient psychotherapies, medication and procedures
Specialist mental health services should offer a range of therapeutic programs for disabling mental health problems in the community. Service provision, clinical research and training are closely linked in the Tier Three facilities but the practice guidelines published by those services should be implemented at all levels of their service delivery facilities.
These are grouped under nine headings: (i) organic brain disorders, (ii) substance abuse disorders, (iii) psychotic disorders, (iv) mood disorders, (v) anxiety disorders, including stress-related, somatoform and obsessive-compulsive disorders, (vi) physiological disorders, including eating, sleeping and sexual, (vii) personality disorders, (viii) intellectual disability and developmental disorders including autism spectrum disorders, (ix) behavioural and relationship disorders of childhood.
All disorders in childhood require wholistic management involving caregivers. See PE4 for a general outline of case identification and assessment and PE2a(i) for infant mental health.
Where children have mental health problems, parents are involved in the process of noting the symptoms, probably working with schools, identifying appropriate treatment options and monitoring and reviewing the treatment. Guidelines for selecting, monitoring and reviewing appropriate treatments are set out below.
In a general sense treatment is successful when symptoms abate and/or the child or adolescent is able to continue or resume daily living activities. Clarifying what type of treatment is best and what to do when one treatment doesn’t work can be challenging.
Parents can be engaged in a psychoeducation model, where the treating practitioner will meet with the parent/s occasionally to update and seek feedback but the work will be mainly done with the child. Such meetings will be with the child’s knowledge and preferably consent. Parent/s can be important in learning strategies to manage their children’s symptomatic behaviour, as well as developing a narrative in the family for the behaviour.
Another model which includes parents is family therapy, where the family is the client. Reviews of effective use of family therapy include Carr (2000), Evidence based practice in family therapy and systemic consultation 1> Child focused problems Journal of Family Therapy 22: 29-60; Cottrell and Boston (2002) Practitioner review: the effectiveness of child and family therapy for children and adolescents. J Child psychology and psychiatry 43(5), 573-586.
Many papers document the effectiveness of family therapy models with eating disorders and school refusal in particular.
Context is important when identifying symptoms or changes in behaviour in children.
PE6a (ix) Behavioural and Relationship Disorders
This section will consider child and adolescent behavioural disorders and family relationship problems but not Juvenile Justice issues which are considered in PE3c ii.
A child’s social development, like all other aspects of development, occurs primarily within a family context. Healthy nurturance by caregivers provides positive reinforcement for socially acceptable behaviours. Socially unacceptable behaviours are shaped by withdrawal of positive reinforcement and introduction of negative reinforcements.
Along with this social learning there is a process of physiological maturation which underpins impulse control, affect regulation, planfulness, awareness of consequences and the differences between self and others. Secure attachment enables empathy and consideration for others to take priority over self-gratification. Insecure children have difficulty with these executive functions and require more positive reinforcement of acceptable behaviour and more systematic management.
Social learning is not a one-way process. One person’s behaviour shapes another’s whilst the latter’s shapes the former’s. A central task is to objectively view events to understand how behaviours are being reinforced. Understanding the “meaning” of behaviours enables a systematic change in what reinforces their continuation and what alternative reinforcement can produce more adaptive behaviour. This is as equally applicable to adult-adult communication as it is to adult-child.
The adult-adult principles are outlined in the following notes from the Relationships Australia website, found on https://www.relationships.org.au. Many of these principles apply in families, parenting, sibling and friendship patterns.
Some conflict in relationships is inevitable, but there are ways to handle it so it is not destructive to you individually or within family and social relationships. Relationships can become stronger if you can talk about differences and stress as a normal part of their relationship. Conflict can often be resolved and serious matters dealt with through respectful communication and a bit of give and take.
The key questions are:
Avoiding conflict, or agreeing not to talk about the issue that caused the conflict, might provide short-term peace. However, it’s better to sort out important relationships issues. Conflict is a symptom – if you patch things up without finding out what’s at the bottom of your differences, you’ll probably find yourselves in conflict again.
People who express their anger without restraint often claim that their anger takes over, and that they can’t help their actions. It may feel as if anger is beyond your control, but in reality everyone can learn to control their response to anger.
Physical violence in intimate and family relationships is a serious criminal offence and is never acceptable as a response to conflict or provocation. If you feel unsafe, it is essential you get help. Get away if it is safe to do so, or call for help. Police Emergency 000
If you find you are getting worked up and starting to argue, there are things you can do to prevent things getting out of hand:
If you want to find out more about Relationships Australia courses that focus on managing anger phone 1300 364 277.
Similar principles underpin the management of child and adolescent behaviour disorders although the younger the child the lesser expectation of internalised controls and the greater reliance on adult-child power imbalance and capacity for limit-setting and application of positive reinforcements.
Childhood behavioural disorders occur commonly in primary school aged children but can also be seen in pre-school children. There are varying degrees of disruptive behaviour disorders recognised by mental health services, with varying degrees of seriousness of outcomes and responsiveness to intervention. The whole life trajectory of the young person is at risk.
The spectrum ranges from:
Early behavioural problems may reflect poor socialisation or responses to stressful environments but may also include other clinically significant predispositions such as mood and anxiety disorders, attention deficit hyperactivity disorder or developmental disorders of autism spectrum or language processing which impair the child’s capacity to meet expectations. It is important to undertake proper assessment of underlying difficulties.
In general, children with seriously disruptive behaviour have less satisfactory school progress and social relationships than children with normal behaviour. This tends to persist and result in poor educational outcomes, less stable partnerships, lower socio-economic levels and higher rates of involvement in welfare and justice systems.
Childhood behavioural disorders can significantly affect other members of the immediate and extended family. Teachers and parents can become frustrated, feel helpless and inadequate because they can’t change the child’s behavior and often feel that their children’s behavior is a reflection of their poor parenting.
Siblings can become embarrassed and ashamed of the behavior and reluctant to bring their friends home. Battles at school and home often ensue with blame by each party of the other – typically parents blame each other, the child, the school and the child feels unheard and without options to change his/her behaviour.
If the child’s disruptive behaviours manifest in delayed development in one or more areas the psychologist is likely to assess cognitive function and developmental markers. This can be very important in identifying children who have learning disabilities which may be affecting their academic performance and their capacity to learn. Many children show behavioural difficulties in association with such delays in areas of functioning.
If a learning disability is identified different ways of learning will be planned so that the child’s strengths can be the focus. Children with Attention Deficit Hyperactivity Disorder (ADHD), a developmental disorder of the neurological impulse-control system, are at risk of developing disruptive behaviour disorders although this is a secondary complication of the underlying ADHD, not part of its syndrome. This pattern may also be relevant in Autism Spectrum Disorders.
Treatment plans may include psychoeducation for parents:
Cognitive behavioural interventions may be helpful with the child if the child is receptive and motivated, but not likely to succeed if the parents or teachers are wanting the child to do this but the child is not ready or open to this. Battles about behaviour should be avoided as far as possible.
Children with behavioural or relationship difficulties are likely to become more challenging in the context of family stress, notably poverty, relationship difficulties between parents, illness in the family, migration. Generally supporting the family to strengthen its relationship is important. Research shows that early intervention can have major beneficial effects in improving the outcome as compared to children who are not helped.
In general, the earlier the intervention, and the less well-established the behavioural disturbance is at the time of intervention, the better the chance of satisfactory outcome.
A pilot program for children with disruptive behaviour has been trialled in some Victorian state primary schools with significant success. The program CASEA (CAMHS and schools early action) has been implemented in schools serviced by four metropolitan (Austin Health, Southern Health, Royal Children’s Hospital, and Eastern Health) and four rural (Gippsland health, Bendigo Health, Ballarat Health, and North Eastern Health) mental health regions.
The program involves a series of small group ‘play sessions’ in which the rules of social behaviour are explored and reinforced. The principles communicated in the sessions are carried over to the daily classroom activities. Concurrently, parent groups explore the principles of behaviour modification.
The research literature and results are published by the Mental Health Branch of the Victorian Health Department.
MHYFVic advocates that this proven initiative of preventive mental health should immediately be made available in all primary schools and that research be undertaken for possible implementation in pre-schools.
The future costs to the community of a behaviourally-impaired life trajectory can be immense, and the savings by a favourable improvement far outweigh the costs of the program. This is an extremely important health initiative not only because it can improve the life of individuals but also the lives of current and future families and friends.
Last updated 19/1/2022
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