Delivering effective psychological therapies and interventions to children and young people
* To reflect the ethos of, ‘The Promise: Independent Care Review’, this guidance takes a broad view of ‘parents’ and ‘family’. The term ‘parent’ is taken to describe all adults who have parenting responsibilities, while ‘family’ refers to biological, kinship, adoptive, foster families and others.
* For this document, ‘clinician’ refers to those who provide psychological interventions or therapies for children and young people.
* This guidance should be read along with the ‘Delivering Effective Psychological Therapies and Interventions to Autistic and Otherwise Neurodivergent People’ guidance.
Mental health difficulties experienced during childhood and adolescence can affect how those individuals and their families negotiate key developmental tasks, and left untreated, this can impact all areas of functioning, and persist into adulthood.
Psychological interventions and therapies for children and young people are often adaptations of interventions and therapies for adults. The evidence-base for psychological intervention and therapy specific to children and young people is less well developed than those for adult populations. More research is needed to clarify the key components of effective interventions for children and young people across different developmental stages. Given this lack of clear guidance, clinicians must provide sensitive and individualised interventions that are flexibly adapted to meet the needs of individual children and young people. Similarly, clinicians are required to make competent use of goal setting and outcome measures to both inform understanding and evaluate interventions. In practice this involves measuring outcomes from multiple perspectives including the child or young person, parents and school.
Good Practice:-
Understanding developmental context
Every child or young person is continually developing as they undergo normal maturational processes. Clinicians require a sound understanding of child and adolescent development, including psychological models of development and an understanding of when input needs to be adapted to suit the age and stage of the child or young person. Be aware that children and young people who were born prematurely, are neurodivergent or who have experienced trauma may have developmental needs that do not necessarily match their chronological age.
Clinicians should be aware that children and young people often do not present with clearly delineated difficulties and that mental health difficulties often co-occur. Some difficulties closely align with developmental stage and care needs be taken to differentiate mental health difficulties from developmentally typical presentations, e.g., certain anxieties are common at certain developmental stages, like a fear of dogs during the early Concrete Operational stage (around 7-11 years of age). These worries should be normalised, rather than pathologised.
Clinicians must adapt their communications to help children and young people understand their meaning as well as encourage children and young people to express their own views and feelings. These adaptations should be informed by the clinician’s knowledge of development stages, including awareness that a child or young person may have an uneven developmental profile, for example, that the child’s expressive language might be better than their receptive language. Adaptations to practice and creative approaches should be used to develop a good, shared understanding of issues and concepts.
Working with parents
Decisions about when to work individually with a child or young person and when to involve parents should be informed by individual as well as broader environmental or systemic factors. The age / developmental stage of the child or young person, and the nature of the mental health difficulty may mean that parents are the focus of the intervention or attend with the child or young person to a greater or lesser extent. Older adolescents may opt not to involve parents at any stage in the assessment or intervention process. Some therapies involve several family members including siblings.
Understanding systemic context
Children and young people exist within familial, social, and educational systems and difficulties must be seen and understood within this context. Understanding how the child, young person and families experience these systems and, for example, any differences between contexts are key to understand the nature of difficulties and to determine the most effective interventions.
Children and young people have a human right to an education and for most, this is provided through the school system. Careful consideration of how a child or young person experiences school informs assessment and effective intervention. Clinicians must be mindful that school attendance may have a significant positive impact upon a child or young person’s overall wellbeing and of the overall importance of access to education for children and young people.
Working with other members of a multidisciplinary team, other services and agencies e.g. in social work or education, requires that clinicians have a clear understanding of their own role as well as the roles and responsibilities of other professionals, services and agencies. Clinicians need to be able to work collaboratively with the child or young person and their family, and this wider group of professionals, understanding and managing different views to work in a co-ordinated way, in the best interest of the child or young person.
Clinicians should aim to provide support that is respectful, responsive to individual needs and which values diversity. Clinicians must be aware of the concept of Intersectionality, e.g., the broader social and political context for children, young people and their families and the potential impact of unequal power relations in their lived experience. This may include experiences of stigma, bias, and discrimination and their impact on mental health and wellbeing. In addition to psychological processes that impact mental health and ability to access services, clinicians should understand the social determinants of health and wellbeing and be aware of their relationship to health inequalities and how these may impact children, young people, and their families and communities.
Power differential
Careful consideration and reflection upon the experience of power within the relationship between clinician and service user is essential for those who work with children, young people, and their families. The power differential that already exists between clinician (as an ‘expert’) and service user is compounded by both the developmental stage and systemic context of the child, young person, and family. Clinicians must avoid language that can lead a child or young person to provide answers that they believe the clinician wishes to hear or attempt to answer a question despite not really knowing the answer. Adolescence is often a time of acute sensitivity to the behaviour and reactions of significant adults, including clinicians. A young person’s apprehension about how their information may be received can inhibit engagement. Clinicians can support this process by maintaining a thoughtful, accepting, and kind curiosity towards the young person’s behaviour, attitudes, and emerging world view.
Clinicians should be alert to the role that the system around a child or young person can have in identifying where a problem is located and correspondingly how the problem might be resolved. Clinicians have an obligation to establish whether children, young people and families have consented to and wish to engage with psychological interventions or therapy.
Knowledge of policy and legal frameworks
Clinicians require up-to-date knowledge and understanding of policy and legal frameworks as they relate to children and young people, including the different sets of legislation and systems in place for young people below the age of 16 and young people aged between 16 and 18. Clinicians also need to know where they can seek further support and guidance in this area (https://www.gov.scot/policies/girfec/).
Responding to risk, child protection and safeguarding
Central to all child protection and safeguarding policy is the statutory responsibility of all adults to keep children and young people safe from harm, even if not working with them directly. It is essential that clinicians have a good understanding of their roles and responsibilities with regards to child protection and safeguarding (https://www.gov.scot/publications/national-guidance-child-protection-scotland-2021-updated-2023/; Public Protection | Turas | Learn (nhs.scot)).
Exploration and risk-taking is a healthy and normal part of children and young people’s development. Clinicians must balance this with the need to remain alert to the presence of adverse events in the lives of children and young people, the potential for significant negative outcomes to occur and impact on the human rights of a child or young person.
Remember that risk is dynamic (cumulative and interactive) and liable to increase or decrease dependent on several individual (i.e., health, mood, attitudes, and perspectives) and social-environmental factors (i.e., family relationships, social circumstances, and stress) that can change over time.
Confidentiality
Clinicians must maintain confidentiality but with an awareness of the limits to this, when risk is present that must be managed. For example, be clear to children, young people and their families about the obligation to share confidential information if it relates to risk, sometimes without consent, and manage this sensitively, e.g., involve children, young people in the process when this is safe and possible.
Information sharing
Consideration needs to be given to relevant information sharing to promote positive outcomes for children and young people. This requires clinicians to balance sharing information and working in partnership with others to support a child or young person’s wellbeing with working within the requirements of confidentiality. This also refers to information sharing between children and young people and their families.
Capacity to give informed consent
Clinicians should involve children and young people in decisions about their care as much as possible. In Scotland, the legal age of capacity is set at 16 years. Clinicians must be aware of the circumstances under which children and young people under the age of 16 can consent to care and treatment, and who can provide consent on a child or young person’s behalf.
Parental responsibility refers to the rights and responsibilities that most parents have for their children’s care. Clinicians should have a clear understanding of parental rights and responsibilities and avoid assumptions about who holds parental rights. For example, where a child or young person lives with a step-parent or is care-experienced.
Obtaining informed consent is an ongoing process throughout contact with a family. Clinicians should be aware that a child, young person and/or family’s capacity to give or withhold consent is not absolute and varies with the nature and complexity of the intervention being proposed, and their perceptions of risks versus benefits.
Further information and training resources are available here:
Children and Young People's Mental Health & Wellbeing: A Knowledge and Skills Framework for the Scottish Workforce https://learn.nes.nhs.scot/49341/
CAMHS Competence framework https://learn.nes.nhs.scot/44058
The Digital Learning Map https://www.digitallearningmap.nhs.scot/
Essential CAMHS https://learn.nes.nhs.scot/15098