SPECIAL REPORT: CHILD & ADOLESCENT PSYCHIATRY
When caring for each unique child, implementing well-being practices are an important addition to therapeutic skills. Addressing and including well-being in our efforts with children better prepares them for the future.1 Effective well-being practices further appear to diminish vulnerability to the impacts of psychopathology,2 including at the genetic level.3 While traditional child psychiatry practice focuses mainly on deficits, difficulties, diagnoses, and dysfunction, an approach centered on well-being expands assessment and treatment for the child’s strengths and opportunities for positive experiences with the family.4 Well-being focuses on good practices for everyone, offering specific alternatives to dysfunctional patterns.
What is well-being? It encompasses multiple broad dimensions of quality of life.5 In addition to physical well-being, also it also includes occupational, intellectual, social, and emotional well-being (collectively, POISE). Well-being is not simply the opposite of illness, and it should be thought of on its own axis. One can have high or low symptoms of physical or mental health problems (eg, diabetes, depression), yet independently demonstrate a range of coping in the POISE domains, from struggling to flourishing. A Gallup poll of United States adults found that compared with those thriving in multiple areas of well-being, those thriving only in physical well-being missed 68% more work and were 3 times more likely to file workers’ compensation claims, 5 times more likely to seek out a new employer in the next year, and more than twice as likely to change employers.6
Figure. POISE Well-Being Assessment: Child/Adolescent Version
Applications in Practice
The Figure provides an efficient instrument we have devised over the past 4 years to assess these POISE domains of well-being for children in a clinical setting, which is freely available for use at www.medstarwise.org/POISE (see: Well-Being Assessment Measure: Child/Adolescent version). Adolescents can complete this form themselves; parents may complete it for younger children.
This measure allows clinicians and families to rapidly identify both general domains of strength and weakness, and to recognize specific topics to address within each domain. The clinician can then include well-being within the treatment plan. For example, a low rating in the sleep item, despite stable scores in all other physical domain items, illuminates a target for intervention. Table 1 shows the well-being interventions to consider for topics within these domains.
Table 1. Well-Being Domains, Specific Topics, and Example Interventions
Creating a Well-Being Plan
Several factors can guide providers as they select and prioritize well-being practices for each patient. First, what matters most to this individual and family? More salient and important goals usually take priority. Second, cultural factors influence well-being, including the values, tasks, and aspirations of each well-being domain. Cultural influences shape how different individuals care for their bodies, manage emotions, and choose relationships, and thus guide individual well-being practices and goals. Third, developmental attunement for each individual remains important; interventions for intellectual stimulation will change across the age span, along with age-appropriate skills for physical activity, time management, emotional regulation, and social skills and relationships.
Motivational interviewing approaches are helpful for youth and families to determine whether they are invested in making a change to achieve a goal.7 Usually a small number of goals (1 or 2) agreed upon by the child and parent, and even shared with others, are easiest to accomplish.
Clinical Case Application
“Samantha,” a 14-year-old female, described symptoms consistent with depression. When completing the POISE scale, she described an inability to fall and remain asleep, then being inactive throughout the day; trying to lose weight by switching to diet sodas; and struggling to get going. At school, Samantha was irritable with staff and was not turning work in on time, and she felt her school was isolating for students with mental health issues. She felt like others were talking about her in the cafeteria and feared that she had few peers who understood her. Samantha could not understand why she felt so sad, and she reported screaming at others who spoke to her.
In addition to treatment for her depressive symptoms, which might include cognitive behavioral and/or antidepressant treatment, well-being practices may also be helpful to alter Samantha’s current routine as well as her future. Sample interventions are provided in Table 2.8
Table 2. Sample Well-Being Interventions for Adolescents with Depressive Symptoms8
In this case, a well-being plan might address all of the POISE domains with interventions preferred by Samantha. For example, in the physical domain, she might be receptive to making changes to her bedtime routine to improve her sleep, to alter her food/drink choices, to increase daily walking, and to create music playlists to make walking more enjoyable. Samantha might initially prioritize 1 or 2 goals, such as “I will walk 5000 steps per day for the next 2 weeks, and monitor my energy level and mood each day,” or “I will replace soda with tea and fruit-flavored waters for 1 week, and monitor the impact on my sleep and appetite.” She could similarly use these POISE domains to identify other subsequent priorities and goals for her health plan. Usually, 1 or 2 goals at a time is preferable so the patient can focus on making these routine well-being behaviors.
Often mood symptoms are a priority for child psychiatrists, and replacing unhelpful behaviors is a vital component of treatment. Table 3 shows a simple approach for youth when they are feeling overwhelmed or employing unhealthy behaviors. In Samantha’s case, identifying specific responses she has, then challenging them with Healthy Alternatives/Reframing/Problem-Solving/Social Supports options, may prepare her with concrete well-being practices to replace these behaviors.
Table 3. Using HARPS To Replace Unhealthy Responses
Not only can well-being interventions be useful adjuvants to specific treatments for patients’ psychiatric symptoms, but they can also help youth address their unique constellation of symptoms and ingrain healthy practices to enhance their quality of life in multiple domains. The lists of preferred and richer evidence-based strategies will continue to grow, so that ongoing recognition and consideration of well-being can become an effective addition to our care of youth.
Dr Bostic is a professor of clinical psychiatry in the Division of Child and Adolescent Psychiatry at MedStar Georgetown University Hospital, Washington DC. Dr Pustilnik is an assistant professor of psychiatry in the Division of Child and Adolescent Psychiatry at MedStar Georgetown University Hospital. Ms Neuwirth is a medical student at Georgetown University School of Medicine. None of the authors report anything to disclose. Dr Charlot-Swilley is an assistant professor and senior policy associate at the Center for Child and Human Development in the Division of Child and Adolescent Psychiatry at MedStar Georgetown University Hospital.
1. Paus T, Keshavan M, Giedd JN. Why do many psychiatric disorders emerge during adolescence? Nat Rev Neurosci. 2008;9(12):947-957.
2. Christner N, Essler S, Hazzam A, Paulus M. Children’s psychological well-being and problem behavior during the COVID-19 pandemic: an online study during the lockdown period in Germany. PLoS One. 2021;16(6):e0253473.
3. Bartels M, Cacioppo JT, van Beijsterveldt TC, Boomsma DI. Exploring the association between well-being and psychopathology in adolescents. Behav Genet. 2013;43(3):177-190.
4. Slade M. Mental illness and well-being: the central importance of positive psychology and recovery approaches. BMC Health Serv Res. 2010;10:26.
5. Health-related quality of life: well-being concepts. CDC. October 31, 2018. Accessed September 7, 2021. https://www.cdc.gov/hrqol/wellbeing.htm
6. Pendell R. Wellness vs. wellbeing: what’s the difference? Gallup. March 22, 2021. Accessed August 30, 2021. https://www.gallup.com/workplace/340202/wellness-wellbeing-difference.aspx
7. Draxten M, Flattum C, Fulkerson J. An example of how to supplement goal setting to promote behavior change for families using motivational interviewing. Health Commun. 2016;31(10):1276-1283.
8. Patkar M. 5 Blinkist alternatives for free book summaries you may not have known. MUO. May 15, 2021. Accessed September 10, 2021. https://www.makeuseof.com/blinkist-alternatives-for-free-book-summaries/ ❒