Parents as Part of the Therapeutic Process in a Child and Adolescent Referral

While some mental health services for adolescents allow self-referral, many require parental cooperation and involvement. The Child and Adolescent Mental Health Services (CAMHS) in the United Kingdom works closely with parents and uses them as "agents for change." CAMHS is a comprehensive network of services, some of which are based in National Health Service settings and others in settings such as schools, youth centers, walk-in centers for young persons, and counseling services.

Parents will typically seek a mental health referral from a general health provider when the child's behavior becomes unacceptable,^1,2 and they may have to negotiate through many perceived barriers to get a referral.^3-5 This is particularly relevant when resources are scarce and general practitioners may have referral quotas for secondary services such as CAMHS. In countries where pediatric mental health services are delivered within the private sector, the situation may be different but is probably influenced by whether insurance is available to pay for treatment. The expectations of parents seeking mental health services for their child will depend on whether they are paying for the treatment, how hard they had to fight to get a referral, how acute the problem is, what the presenting problem is, and how disturbed they are about his or her behavior.

Research suggests that parents who assertively seek a referral for their child will generally get one.^2,4,5 This is particularly true if the behavior is an externalizing problem and if the child's school suggests that without a referral he may lose his place in school. Because of the readily available information on the Internet, parents will come armed with expectations of a diagnosis and a treatment plan. They may have their own agendas, and they may be worried that their child has a serious illness or that, because of a family history, he will inherit a certain condition. The first meeting with the family is therefore very important.

In his review article on the therapeutic relationship, Green⁶ stresses the importance of the initial interview, because it will set the stage for future contact with the family. Extrapolating from Hougaard,⁷ he suggests that certain factors are important in a successful partnership:

• The motivation of the parent to take part in the assessment and treatment process.
• The personal alliance between the therapist and parent (empathy, warmth and acceptance, authenticity).
• The task alliance (understanding the task; perceived competence of the therapist; and a shared agenda for the goals, methods, focus, and "depth" of treatment).

In a recent article, Kazdin and coauthors⁸ also found that the therapeutic relationship was the most important factor for a positive outcome in children with oppositional, aggressive, or antisocial behavior. We have been investigating this alliance with parents and their motivation⁹ in our recent parenting program (funded by a grant from Wessex Hope).

The ability of parents to work with treatment teams or individual professionals will depend on their own agendas and attributions. Do they view their child's problems as internal and under his control, or do they view the problems as external and not his fault? The latter is where parents of children with attention-deficit/hyperactivity disorder (ADHD) may fit. On one level this is a helpful view, since it allows the parents to stop feeling guilty. If parents feel blamed for their child's behavior, they may be incapable of working toward change. On the other hand, if the child and parents blame family or genetic history, then it could be harder for parents to move to a position in which they are responsible for changing the unacceptable behavior.

There is increasing evidence that in addition to medication, working with the family and the child to make life changes is important if only to increase compliance with medication and to tackle the comorbid difficulties that are often present.^10,11 Because preschool children with ADHD are more likely to have adverse effects with medication, parent training is particularly important before the consolidation of a difficult parent-child relationship.^12-14