Margaret Thompson, MBChB, MD

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,

 and they may have to negotiate through many perceived barriers to get a referral.

 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.

 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, Green

 stresses the importance of the initial interview, because it will set the stage for future contact with the family. Extrapolating from Hougaard,

 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 coauthors

 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 motivation

 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.

 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.

The task is to have parents acknowledge that they are also responsible for managing their child's problems. Kazdin and colleagues 

 have written of the barriers to change. In addition to work and family responsibilities, time will need to be allocated for appointments with the mental health professional. Parents will need to persuade the child to attend appointments, do homework suggested by the therapist, and take medication. They will also have to face the financial impact of their child's problem, including expenses for traveling to and from appointments and child care for their other children.

Which factors may make it difficult for parents?

Parents' own agendas will have to be acknowledged, if not addressed, before changes can be made in the child's behavior. The parents' background and their own upbringing may shape their self-worth, well-being, and ability to take on the work involved with a child who has a problem. This, in itself, may contribute to the child's behavior problem with a negative impact on discipline, limit setting, and having the child be the focus of attention.

Although parents with mental illness may be good parents, many find the task of parenting very difficult. A parent who is not on medication may be depressed and have no energy; consequently, the children may be neglected (eg, not stimulated, protected, or monitored), which would result in behavior problems. Parents with mental illness are more likely to be living on their own or with a partner who also has a mental illness. They may well be the victims of violence and abuse, and their children may also be at risk.

Parents may be reluctant to admit that they have a mental disorder because of the stigma associated with it and the fear of losing their children.

 In the United States, 50% of parents with a serious mental illness have had their children taken away.

 When children whose mothers had a postpartum illness were followed up to age 5 years, they were found to have cognitive delay and social interaction problems; this particularly affected boys.

 This was compounded if the child also had a difficult temperament. The combination of a child with a difficult temperament and a parent with depression can lead to a hostile interactive parenting style; in this setting, behavior problems were more likely to develop in toddlers.

 found that mothers who had had a difficult labor and depression were more likely to say that they had not bonded with their infant--often feeling very angry and sometimes murderous towards the child, which continued into the preschool years.

A child who has a difficult temperament with poor emotional regulation, who is hyperactive, and/or who has extreme temper tantrums is difficult to parent. The child needs parents who are able to contain and soothe dysregulated children.

The parent-child relationship is important because it allows the child to develop a sense of self-worth and problem-solving skills as well as the skills to cope with emotions. Parents are taught to encourage their child to "mentalize"--use language to make sense of surroundings, and communicate thoughts and feelings using words rather than anger or violence.

 Parents are trained to understand their child's abilities and encourage the development of new skills appropriate to both his physical and emotional levels.

 If the parent finds it difficult to handle a dysregulated child, then a harsh coercive cycle of relating can ensue.

Parents who do not have the support of friends or family may find parenting more difficult, as may parents who are poor or have to work long hours with low pay and who may only be able to afford lower standards of child care. As already mentioned, parental ill health (mental, but also physical) may contribute to poor parenting.

Being disorganized will make parenting more difficult, especially if the child is also disorganized. Parents who had high scores on adult ADHD rating scales were less able to use a parenting program for children with ADHD.

 Mothers who had had a poor experience as children used parenting groups less well.

As evidenced by high expressed emotion (EE), parents believed that children with ADHD were more difficult

 and subsequently had less interaction with them. Interestingly, mothers who had high scores on adult ADHD rating scales had lower EE scores toward their sons--who also had high scores on ADHD scales--possibly because they empathized with their children.

 illness, confidence, and capacity for change determine how the therapeutic relationship will proceed.

What do we need to do in the clinical setting?

It is important to allow parents time to tell their story. Careful thought must be given to who will be seen first, but it is even more important to allow time to see the parents and child separately. The time with the parents can be used to discuss difficult matters concerning the child or the family, and the time with the child can be spent discussing topics he may be reluctant to speak about in front of his parents.

Family members can become angry for various reasons, eg, if they believe that they have not been heard or if they think that they are not believed. For some families it may be too difficult to give up the problem--the family may have no capacity for change, or change may be too painful for the family to deal with. Perhaps changes were introduced too quickly and did not proceed at the family's pace. The parents may have had a difficult childhood or may have been in an abusive relationship, potentially making it difficult for them to trust a mental health professional.

One of the first steps in treatment decision making is taking a thorough family history as well as a history of the child's problem. This is often when "ghosts in the nursery" appear.

 A family tree is a useful way of making sure the therapist knows the importance of relatives and their past and present relationship to the family, as well as psychiatric and physical histories. It is also useful to take a developmental history of the child. Difficult teenagers were usually difficult toddlers, so there will be a long history of problems in the parent-child relationship.

Parents are worried about their children and expect to be part of the discussion about treatment plans. However, before making any treatment decisions the therapist may need to consider the following:

1. What happens when a 6-year-old tells the therapist about harsh punishment? If the child seems at risk, he will need to be told that the therapist will have to report it in order to help his parents. Careful consideration will need to be given as to whether the child goes home or not.

2. If an adolescent admits to taking drugs, should the parent be told? If he is not at major risk and the drugs are "soft," (eg, cannabis, ecstasy, amphetamines) it may be the right decision not to tell a parent but to strongly advise the patient to do so himself. The risks of taking drugs should be discussed along with available substance abuse services. This is particularly important if the patient has ADHD or any family history of psychotic illness. If hard drugs, such as heroin or cocaine, are being taken, the patient is clearly at risk. The duty of care would strongly suggest that the parent needs to know in order for help to be initiated.

3. If a young person says that he is suicidal and has hidden pills at home, but he does not want his parents to know, what should the therapist do? If despite persuasion he is adamant that his parents cannot be told, discussion about options is important. For the maintenance of the future therapeutic relationship, another relative might be identified to act as a responsible adult. An agreement can be made that the patient will stay safe until arrangements for an early return to the clinic are finalized. It is very difficult to be confident that the patient will not make another suicide attempt, but positive factors that would indicate that a patient is at a lesser risk for suicide include:

He makes it clear that he has positive aspirations for the future (eg, exams to take, career ideas).

	    There is no evidence of depressive illness, psychosis, or major drug or alcohol abuse.

	    There is no evidence of repeated overdose or plans for an overdose in the future.

If, however, it is clear that the patient cannot give any guarantee that he can keep safe, or there are factors that would indicate that he is at risk, then the parent will have to be told in order to plan for safe care.

Each situation needs to be worked out individually, and each has its own ethical confidentiality issues, especially in such cases as self-harm, abuse, or eating disorders. The child's safety is paramount. If the therapist can keep the child safer by not telling parents, that may be the right decision. Often, talking to the patient, working out the script to be used with parents, and talking with the parents while the patient is present will maintain trust and keep the parent-therapist dialogue open. Discussion with a colleague and recording each conversation is important; discussion with medical insurance providers might be necessary as appropriate.

The following case vignettes provide examples of difficulties that can be encountered with parents of child and adolescent patients.

Mrs H was very angry with the mental health team because the behavior of her daughter Jane (aged 6 years) continued to cause her problems. Mrs H received a lot of parenting advice and support. Jane also had problems at school and Mrs H was angry with the school, as well. Mrs H had a background of parental abuse, had been depressed, was in a difficult, violent relationship, and had fallen out with all the health professionals she had seen in the past. She felt blamed. She often missed appointments or stormed out. We always tried to arrange appointments to suit her. We offered her appointments on her own and with her child. She wanted the child to be "made better." We reviewed the situation and asked for a second opinion at a regional clinic. This clinic admitted the daughter and diagnosed her behavior in the autism spectrum. The mother changed her therapeutic team and felt vindicated, although she still finds her daughter to be hard work.

This case illustrates that when dealing with an angry parent, it is sometimes necessary to stop, take another look at the problem, and try to understand why the parent is angry. A reevaluation may be required to confirm that the initial assessment was correct.

When a family is proving difficult to work with, it can be helpful for therapists to work in pairs. This allows one therapist to monitor the conversation while preventing the other from becoming drawn into an argument or a hostile exchange. It is often useful to have a witness to these interviews, and in this case, it might be helpful to encourage the mother to have a support person also. Two therapists make it possible to have both "good" and "bad" persons present, if that is important to the therapy. It would be especially helpful with angry parents if both a male and a female therapist were available.

A reflective team might be helpful if the situation were at an impasse. Staff members would be available to talk to the family before the session, thus enabling therapists to work out the issues. With the family's consent, members of this team could either be behind a screen or, if necessary, in the room and available for advice throughout the session. Finally, it is important for medicolegal purposes to document all communication.

Mrs D presented with her son Peter (aged 6 years) who had problems with controlling his temper and was extremely oppositional. She had had a very difficult pregnancy and long labor, followed by a caesarean section because of fetal distress. She had postnatal depression following the birth of this child and had had to spend some time in the hospital. Her husband looked after the child while she was in the hospital because she was too ill to have the baby with her. She admitted to the therapist that she had never bonded with Peter and blamed him for her illness. She found it very hard to even cuddle or comfort him as a baby. Although this had improved somewhat, she still had a very different relationship with him than with her 2 younger children.

The therapist spent a few sessions with Mrs D helping her grieve the "loss" of the good pregnancy and difficult birth of Peter. Then Peter and his mother participated in guided play. They worked together in the clinic with a therapist and the relationship gradually began to improve.

Mrs W had a very hyperactive little boy, James. Mrs W was also very overactive and found it very difficult to organize herself.

The nurse worked hard with Mrs W, helping her establish routines to organize her day. Suggesting that Mrs W might also have ADHD, she recommended a referral for ADHD assessment. Once the mother was able to listen and take on ideas about a different way of parenting her son, things gradually improved for them both.

Dr Thompson is a reader in child and adolescent psychiatry at the University of Southampton in the United Kingdom. She is also a consultant with the CAMHS of Ashurst Hospital in the Southampton City Primary Care Trust. She reports no conflicts of interest concerning the subject matter of this article.

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 Sonuga-Barke E, Daley D, Thompson M. Does maternal ADHD reduce the effectiveness of parent training for preschool children's ADHD? 

Articles

While some mental health services for adolescents allow self-referral, many require parental involvement. There is increasing evidence that working with the family and the child is important if only to increase compliance with medication and to tackle any comorbid difficulties.

Margaret Thompson, MBChB, MD

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