Understanding the Levels of Mental Health Care available for Children and Adolescents

A Guide for Parents and Guardians

Table of Contents:

Introduction

1. Structured and Consistent Learning and Play
   • a. Social Opportunities
   • b. Group Play/ Coached Play
   • c. Exercise/ Physical Activity
   • d. Getting Adequate Sleep and Eating a Diet Low in Processed Foods and Sugar
2. Individual Counseling / Play Therapy
3. Individual EMDR Therapy or Mind-Body Therapy (Mindfulness Based Stress Reduction)
4. Family Therapy
5. Intensive Family Therapy
6. Behavioral Coach for the Child/ Adolescent and Evidenced-based Parenting Programs
7. Group Therapy or Group Psychoeducation Classes
8. Intensive Outpatient Program (3-4 days a week)
9. Partial Hospitalization Program (4-5 days a week)
10. Inpatient Hospitalization
11. Long-Term Hospitalization for Mental Health
12. Chemical Restraint (Psychotropic/ Psychiatric Medications)
13. Long-Term Outdoor (Adventure/Camping) Behavioral Modification Program
14. Long-Term Residential (Including Education) Behavioral Modification Program

Introduction

It seems like every week I get asked questions such as, “What should we do with our child?” “I feel like we’ve tried everything…so how do I know that anything will work?”

Parents often tell me that their primary care practitioners recommended Psychiatric Medications as a “first line” of treatment without even discussing counseling, the child’s environment and activities, or behavioral modifications. In my opinion, this type of prescribing without education is likely to cause long-term damage to the child/adolescent and families and should be considered malpractice.

In this article, I will attempt to be comprehensive with ideas and solutions for the mental health of children and adolescents. I will begin by describing basic, preventative measures that are empirically proven to be healthy. These are non-clinical, and parents can do them at home. Then I will move onto clinical interventions which require the expertise of a mental health clinician (LPC, LMSW, LMFT, LP, etc.), starting with the most basic interventions before climbing up the ladder of severity to the highest levels of treatment.

 

• While Inpatient Hospitalization is considered the 9^th level of treatment in this article, if there is an emergency situation where you believe your child or adolescent’s life is in danger or if you believe they may be threatening the life or safety of another person or animal, do not hesitate to call 911, the national suicide prevention lifeline, or bring them directly to the hospital for inpatient hospitalization. Inpatient hospitalization is not ideal for anyone, but it saves lives every day! For many children and adolescents who are in a mental space that is heading toward a catastrophe, the reset of an inpatient stay is life saving and transformative. Such a stay can also help the parents by giving them a sense of security while, at the same time, giving them the time needed to contact professionals to get a plan set up for aftercare.

 

Levels of Treatment from Lowest to Highest:

 

1. Structured and Consistent Learning and Play (Non-Clinical)

Children and Adolescents thrive with structure and consistency. Thus, parents/caregivers need to make sure that they have some degree of structure and consistency in their child/adolescent’s life both in their schooling and in their play opportunities. Their brains and bodies are still very much in the development stage, which means that most of them err toward having an “external locus of control.” This means that their social environment, the parenting/caregiving, the teaching, and the learning and play opportunities are more impactful and have a higher degree of an effect on children and adolescents as they grow and develop an “internal locus of control.” Children and adolescents that grow up in a “safe” and “predictable” environment with structured and consistent learning and play opportunities are likely to develop better emotional regulation, distress tolerance, and ability for “self-control.” This is because their brains are being wired for predictable patterns. Then, later in life, it will be easier to learn to “improv” because they have the basics correctly installed. Parents must not make the mistake in believing that their child “thinks like an adult.” This is a common error parents make as the child does not have the skills to self-regulate without the parent or caregiver and will not have them until late adolescence. The good news is that children are HIGHLY adaptable due to the neuroplasticity of their growing brains. That means that in as little as 60-90 days, if parents/caregivers work to give them structured and consistent learning and play opportunities, the child should learn to adapt and grow.

 

• • A. Social Opportunities (Non-Clinical)

1. 1. 1. It is VERY important that children and adolescents have ample social opportunities with diverse groups of peers, in multiple types of activities. These social opportunities can prevent “social anxiety” later in life and give the child practice in how to adapt to many different social scenarios.
      2. Parents should not rely on children to make their own social arrangements until they are at an age where the child begins to initiate this on their own. If the child is isolative, it is imperative that the parents make “play dates” with other children and families that share their interests. These social opportunities should be weekly—at the least.
      3. Research has shown that isolation increases and amplifies almost every negative mental health symptom in the Diagnostic and Statistical Manual of Mental Disorders. While a balance is needed between extraversion and introversion, the basic conclusion is that isolation is BAD for children and adolescents. Humans are most closely related to “pod mammals” and thus, we do well in close proximity to others (as long as the others are not hurting us).
      4. In the digital age, “online hangouts” do not count for social opportunities, due to the amount of body language and interpersonal exchanges that social opportunities provide (save for a pandemic).

 

• • B. Group Play/ Coached Play (Non-Clinical)

1. 1. 1. Play is vital for children/adolescents’ mental health and healthy brain development. Some examples of group/coached play are: organized sports, dance, theater productions, band class, choir, rock band, casual sports, art and pottery groups, or imaginative play.
      2. Research shows play can improve children’s abilities to plan, organize, get along with others, and regulate emotions. In addition, play helps with language, math, social skills, and even helps children cope with stress.

• • C. Exercise/ Physical Activity (Non-Clinical)

1. 1. 1. Amid a childhood obesity epidemic in the United States, it almost goes without saying that exercise/physical activity is essential to the physical health of all children and adolescents; however, exercise and physical activity is also correlated with better mental health. On the other hand, a more sedentary lifestyle (sitting on the computer, TV, and/or playing video games) is associated with poor emotional regulation, low self-control, and inability to focus on school work, reading, and other enrichment activities.
      2. Experts agree that physical activity allows children to have a better outlook on life by building confidence, managing anxiety and depression, and increasing self-esteem and cognitive skills.
      3. A recent large study concluded that even if children exercised only one to three days a week, there was a strong correlation with lower rates of anxiety and depression — and there was no significant difference between those who exercised one to three days a week and those who exercised four to six days a wee
      4. Good sleep duration and extracurricular activities are also associated with better mental health. In fact, physical activity may improve sleep quality, which is closely linked to mental health.

• • D. Getting Adequate Sleep and Eating a Diet Low in Processed Foods and Sugar (Non-Clinical)

1. 1. 1. A consistent bedtime and wake time is not just old-world knowledge that we inherited that is without merit. A consistent bedtime and wake time actually works on the circadian rhythms in the brain which can influence: hormone release, eating habits and digestion, and body temperature.
      2. Children and Adolescents need more sleep than adults for a variety of reasons. The Centers for Disease Control (CDC) have cited a number of studies demonstrating that adequate sleep is crucial in the prevention of: Type 2 Diabetes, Obesity, Poor Mental Health, Injuries, Attention, and Behavioral Problems.
      3. We live in a world where processed foods and sugar-filled snacks are ubiquitous. Unfortunately, most children are eating far too much sugar and processed foods—and while we all know that this will affect physical health, there are indicators that it can negatively affect mental health as well. In fact, The American Association of Pediatrics recommends for parents to aim for less than 25 grams (about 6 teaspoons) of added sugar per day for children 2 years of age and older.
      4. Recent research has indicated that heavy sugar consumption is tied to an increased risk of depression and worse outcomes in individuals with schizophrenia.

 

2. Individual Counseling / Play Therapy (Clinical)
   • While the research on individual counseling for adults is astounding (with an effect size of .8), the results are not often the same for children and adolescents for a variety of reasons.
   • We know from pediatric medicine, neuroscience, and the field of psychology that children and adolescents do not yet possess the ability to be completely independent and thus treating them like an adult and sending them to individual counseling is more palliative than anything and is not as effective intervention without a great deal of participation from the parents/caregivers.
   • The child and adolescent is part of a family system—they are not independent thinkers yet. Therefore, the family dynamics are a large part of how a child feels about themselves. Individual therapy will certainly not hurt a child or adolescent, and it can help them with self-esteem, mental health concerns, and more. However, many parents are frustrated with the results that they see at home because the problem behaviors may not be addressed fully without the context of the family.

 

3. Individual EMDR Therapy or Mind-Body Therapy (Mindfulness Based Stress Reduction)(Clinical)
   • Eye Movement Desensitization and Reprocessing Therapy (EMDR) has been considered one of the best treatments for post-traumatic stress disorder (PTSD) for the past two decades. Research on this type of therapy has focused mostly on adults with PTSD. However, more recent research has shown that EMDR reduces both PTSD symptoms and anxiety symptoms in children after 6 weeks. These results were seen in adolescents as well with implications that it also reduced symptoms of depression. EMDR is an 8-phase approach that focuses on retraining the brain to
   • Mind-Body interventions or Mindfulness Based Stress Reduction/ Mindfulness Based Cognitive Therapy.
     • Mindfulness Based Stress Reduction (MBSR) therapy is a meditation therapy, though originally designed for stress management, it is being used for treating a variety of illnesses such as depression, anxiety, chronic pain, cancer, diabetes mellitus, hypertension, skin and immune disorders.
     • Mindfulness-based cognitive therapy (MBCT) is a type of psychotherapy that involves a combination of cognitive therapy, meditation, and the cultivation of a present-oriented, non-judgmental attitude called “mindfulness.”
     • Research shows that mindfulness is linked to lower stress and anxiety, and improvements in self-control, attention, resilience and better academic performance in youth.

 

4. Family Therapy (Clinical)
   • Family therapy involves all members of the family attending sessions together. This is helpful if there are conflicts within the family, but even if there is one particular member who is struggling (e.g. addiction, serious mental illness like schizophrenia, anorexia nervosa, etc.), family therapy can be used to teach other family members about how to cope with the troubling behaviors.
   • Sometimes family therapy works best in conjunction with individual therapy, and sometimes it works well with just the parents. Talking with a licensed family therapy provider helps families figure out a plan that works best for them. Working with the family as a whole usually involves improving the relationship among family members by enhancing communication, resolving conflicts, and reducing negativity. Family therapy involving only the parents usually involves learning effective parenting techniques, implementing appropriate consequences, and learning about how children communicate and how their behaviors are reinforced.
   • Parents often worry about sending their children to therapy without them if that is what would be best for the family. They may worry that the child is keeping secrets from them or not giving the therapist the best account of what is happening. However, your therapist will let you know the general issues your child is having and how to best help them. The therapist does not “take sides” and will keep you informed about the best scenario for your child. By being honest with your therapist, they can more effectively help the entire family. If you have questions about confidentiality, let your therapist know–every situation is unique, and having trust in your mental healthcare provider is an important component of effective care.

 

5. Intensive Family Therapy (Clinical)
   • Sometimes a child’s behavior combined with the dynamics of the family situation are too much for once-a-week family therapy. In these situations, it is important to increase the frequency of the family therapy to at least 2 sessions per week in addition to other mental health interventions (e.g. individual therapy, group therapy, and even behavioral coaching).
   • The goal of intensive family therapy is to help families feel more connected and cohesive, and to better balance multiple stressors that are overpowering their lives. Intensive family therapy can help parents/caregivers and their children have hope that their family can successfully grow and develop.
   • This type of therapy can be appropriate for life-cycle challenges such as: divorce or remarriage, separation, illness, loss/grief, trauma, depression, anxiety, self-harm, aggression, eating disorders, substance abuse, suicidality, truancy, oppositional behavior, and general family conflict.
   • It is important to work with a clinician who specializes in this area to determine what the best treatment plan will be. For some families, a brief duration of frequent visits may be useful, while for other families, a couple sessions a week may provide the same amount of benefit over a longer period of time.

 

6. Behavioral Coaching for the Child/Adolescent and Evidenced-based Parenting Programs (Clinical)
   • Behavioral Coaching for the Child/ Adolescent  The group teaches parents skills to increase desirable behaviors and decrease undesirable behaviors of their teens, to improve the quality of their relationships with their teens, to enhance communication, to effectively problem-solve and negotiate, and to manage unhelpful thoughts and emotions in response to teens.
   • Evidence-Based Parenting Programs: Evidenced-based parenting programs (a subset of the larger body of evidence-based programs) have been specifically developed to strengthen families, prevent youth and family problems and promote family and child well-being. These programs have been rigorously evaluated and have demonstrated scientific evidence of improving child, parent and/or family functioning.

7. Group Therapy or Group Psychoeducation Classes (Clinical)
   • Because children/adolescents are naturally focused on themselves and what feels good to them, it can be helpful for them to begin to understand how others think and feel. Learning about the varying personalities and problems of their peers can increase their empathy as they begin to work together to learn coping skills and navigate the issues of their peer group.
   • Examples: Dialectical Behavioral Therapy groups for children/ adolescents, Mindfulness Based Stress Reduction classes, Emotional Regulation classes, traditional reflection group therapy with children/ adolescents.

 

8. Intensive Outpatient Program (3-4 days a week) (Clinical)
   • Outpatient programs are designed to support children at a higher level than weekly therapy. This type of setting can be useful if going to an inpatient treatment center would be disruptive to the child’s life. Outpatient treatment is usually daily for one to two months and can be done after school in some situations.
   • Typically, outpatient programs are reserved for children with severe forms of mental illness or behavioral problems. These may include: anxiety, depression, anger, aggression, bipolar, eating disorders, obsessive/compulsive disorder (OCD), substance use, grief, mood disorders, personality disorders, trauma recovery, and more.

 

9. Partial Hospitalization Program (4-5 days a week) (Clinical)
   • Partial hospitalization programs are for children who are experiencing behavioral health symptoms which cannot be adequately treated in a traditional outpatient setting, but are not severe enough to require 24/7 monitoring for safety.
   • Oftentimes a hospital will recommend this after an Emergency Room Visit, a Crisis Center Visit, or time spent in an intensive outpatient program.
   • Most programs meet during business hours and provide therapy, psychoeducation, and other activities for mental and physical health.

 

10. Inpatient Hospitalization (Clinical)
    • Sometimes it is necessary to get a child out of their environment and into a treatment-focused setting.
    • In these situations, it is important to let many professionals assess your child and make sure that they are safe.
    • Inpatient hospitalizations typically include: Group Therapy, Psychoeducation, Group activities, One-on-One Therapy, meetings with a psychiatrist and more.

 

11. Long-Term Hospitalization for Mental Health (Clinical)
    • For children whose symptoms are so severe that they require 24/7 monitoring for their health and safety (and the safety of others),
    • It is rare, but sometimes, children and adolescents need more than just a “pattern reset” from an inpatient hospitalization stay.

 

12. Chemical Restraint (Psychotropic/Psychiatric Medications) (Clinical)
    • These are not recommended as a first, second, or even third line of treatment by any treatment organization in the United States. While they can be life-saving in certain cases, they should not be seen as a panacea that will “fix my child’s behavior.”
    • In many cases, prescribing psychiatric medications to children and adolescents can actually obscure the actual problem that is going on, instead of fixing it. Many parents are happy if their child is “mellowed out” or now has the “superhuman ability to focus”—but, this chemical effect is often a “band-aid” for a larger systemic problem, an environmental problem, a childhood development issue, an emotional regulation issue, or any of the issues discussed in this article pre-treatment. In fact, the long-term implications of children ingesting psychotropic medications has not been fully studied, and children given such drugs are taking them “off-label” as their effects (including suicidality) have not been studied in children.
    • Giving children and adolescents psychiatric medications should be almost a last resort, as the child’s brain is still developing and the brain can easily be changed by consistent behavioral modification, limits, and incentives in just 90 days. The entire field of neuroscience recommends that medications be used sparingly and avoided if possible, with anyone under the age of 18.
    • The American Psychological Association’s resolution on psychotherapy effectiveness contains more than 50 peer-reviewed studies on psychotherapy and its effectiveness in treating a spectrum of health issues and with a variety of populations, including children, members of minority groups and the elderly. Psychotherapy teaches patients life skills that last beyond the course of treatment. It also reduces disability, morbidity and mortality; improves work functioning; and decreases psychiatric hospitalization. Furthermore, the results of psychotherapy tend to last longer than psychopharmacological treatments and rarely produce harmful side effects.
    • While medication is appropriate in some instances, research shows that a combination of medication and psychotherapy is often most effective in treating depression and anxiety. It should also be noted that the effects produced by psychotherapy, including those for different age groups and across a spectrum of mental and physical health disorders, are often comparable to or better than the effects produced by drug treatments for the same disorders. Mental healthcare providers can work with the child’s medical team to provide integrative care. In general, psychotropic medications should only be used in the cases of severe mental illness or harm to self/others.

 

13. Long-Term Outdoor Therapeutic (Adventure/Camping) Behavioral Modification Program (Clinical)
    • When a child’s normal environment is not conducive to healthy development, a change of environment may be necessary. Month-long, therapeutic wilderness programs can set your child up for lasting change. These experiences are different than typical “camp” experiences, and are led by licensed professionals.
    • Adventure therapy uses experiential learning activities in outdoor environments to promote behavioural change. Adventure therapy utilizes an eclectic therapeutic approach, drawing on aspects of cognitive-behavioral, systemic, existential, psychodynamic, and occupational therapy. Adventure therapy may be used as a form of brief intervention or used as part of an integrated healthcare approach. Adventure therapy empowers participants by providing fun and engaging activities that involve real obstacles. Activities are sequenced for success in order to provide participants with a sense of self-efficacy and mastery. Adventure therapy activities can include problem-solving activities, ropes challenge courses, outdoor adventure activities, and extended overnight expeditions involving backpacking, canoeing and rafting, ski touring and/or snow camping. Meanings derived from participating in adventure therapy programs are intended to be incorporated back into the participant’s individual and social world.
    • Results include: increased self-confidence, personal insight, assertiveness, sociality, clarity of future plans, increase in coping skills, a reduction in reported emotional problems, a slight increase in self-esteem, increased sense of hope, perseverance, problem-solving, self-sufficiency, willingness to access support, and returning to school.

 

14. Long-Term Residential (Including Education) Behavioral Modification Program (Clinical)
    • Considered the most intensive form of treatment, long-term residential programs target severely troubled youth who pose a risk to themselves or others. Similar to inpatient and hospitalization programs, these programs provide 24/7 care.
    • Unlike other programs, however, these programs usually provide academic studies and recreation in addition to therapy and personal growth interventions.
    • This treatment option may be appropriate for adolescents with relapse problems, eating disorders, self-harm, criminal or violent behavior, trauma, sexual deviance, or personality disorders.
    • It is a hard decision to place a child in this type of setting; however, the outcomes for attendees are very good. Research has shown that, after a 1-year follow-up, almost 90% of teens were living at home and not in another form of clinical treatment. Additionally, around 90% of parents saw positive, lasting changes in their children.

 

 
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Disclaimer: This document was created by Paul Krauss MA LPC for educational purposes only. This document contains the opinions of Paul Krauss MA LPC and should not be taken as the “definitive opinion” or “absolute psychological or behavioral opinion” on any subject. Consuming this document is not a substitute for medical, psychological, counseling or any other sort of professional care. Consumption of these materials is for your own education and any medical, psychological, behavioral or professional care decisions should be made between you and your therapist, counselor, interventionist, behavioral health expert, primary care doctor or another provider that you are engaged with.